r 


v 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


^   TEEATISE 


ON   THE 


HISTORY,  ETIOLOGY  AND  PROPHYLAXIS. 


BY  JOHN  M.  WATSON,  M.  D., 

PROFESSOR     OF     OBSTETRICS     AND    THE     DISEASES     OF     WOMEN     AND    CHILDREN,     IN  THE     MKDICAI 
DEPARTMENT     OF    THE     UNIVERSITY     OF     NASHVILLE. 


THIRD    EDITIOU. 


NASHVILLE,  TENN. : 

E.  Q.  EA3TMAN   &  CO.,  PRINTERS,  UNION   AND  AMERICAN  BLOCK 

1859. 


TO 

JAMES  E.   WENDEL,  M.  D., 

This   Volume 
IS  MOST  KINDLY  AND  RESPECTFULLY  INSCRIBED, 

IN   HIGH    CONSIDERATION    OF 

His  Great  Professional  Attainments,  Practical  Skill, 
and;  Sterling:  Qualities, 

Closely  tested  by  the  Author  during  ten  years  association  with  him,  as  a 
co-partner  in  the  practice  of  Medicine. 


M35$6m 


PREFACE. 


It  is  scarcely  expected  that  in  this  age  of  book-making, 
an  author  should  stop  to  apologize  for  publishing  his  work, 
jet  it  may  not  be  amiss  to  make  a  few  statements  in  regard 
to  the  one  now  about  to  be  offered  to  the  professional  public. 
This  monograph  was  first  published  in  a  series  of  numbers 
in  the  Nashville  Journal  of  Medicine  and  Surgery.  It  was 
then  well  received  by  the  profession,  and  favorably  reviewed. 
Shortly  after  appearing  in  the  aforesaid  Journal,  it  was 
published  a  second  time,  in  a  pamphlet  form.  The  work"  in 
its  present,  or  third  edition,  will  be  greatly  enlarged,  and  will 
contain  two  costly  original  plates,  and  consist  of  about  eighty 
pages  neatly  and  substantially  bound  in  one  volume. 

The  author  has  just  cause  to  hope  that  it  will  again  meet 
with  a  kind  reception  by  the  profession,  especially  as  he  is 
not  aware  that  any  regular  monograph  has  ever  been  pub- 
lished on  the  fatal  malady  of  which  this  treats,  a  reason 
which  he  may  offer  as  a  further  apology  for  the  present  one. 

Trismus  Nascentium,  or  Lock- J  aw  of  Infants,  is  no 
uncommon  disease,  but  one  which  is  constantly  occurring  in 
our  midst.  No  condition  or  habits  of  life,  peculiarity  of 
'climate  or  race,  give  immunities  from  its  attacks.  The 
umbilical   cord   must    of    necessity   separate   from   its   vital 


VI.  PREFACE. 

connections  with  the  umbilicus,  either  by  a  healthy  or  a 
diseased  action,  and  to  show  how  the  latter  may  be  counter- 
acted, and  tetanus  thereby  prevented,  constitutes  the  main 
design  of  the  writer.  The  physiology  of  the  separation  of 
the  cord  has  been  studied  only  by  a  few,  while  its  pathology 
has  been  almost  disregarded !  Even  the  special  anatomy 
of  the  umbilicus  of  the  infant  has  by  no  means  received 
the  attention  and  consideration  which  it  so  justly  deserves. 
The  parts  which  enter  into  the  formation  of  the  infantile 
umbilicus  are,  of  course  known  and  described  by  anatomists, 
but  neither  their  physiological  nor  pathological  changes, 
which  they  undergo  while  the  cord  is  separating,  are 
studied  or  regarded  by  the  practitioner  as  they  should  be, 
especially  that  diseased  state  of  the  parts  which  is  so  apt  to 
excite  infantile  tetanus. 

The  funis  with  its  membraneous  covering,  its  gelatine  two 
arteries  and  vein  may  desiccate  Kindly,  and  separate  from  its 
connections  with  the  umbilical  ring  without  irritation,  inflam- 
mation, suppuration,  or  sloughing.  After  which  the  navel 
may  contract  and  close  up  without  disease  of  any  kind  what- 
ever ;  but  we  are  bound  to  admit  that  there  is  often  a  failure 
in  this  remarkable  physiology,  and  that  the  parts  are  greatly 
disposed,  all  this  time  to  pass  into  a  diseased  state  which  may 
produce  the  lock-jaw  of  infants.  Even  if  the  cord  come 
away  without  leaving  any  obvious  appearances  of  inflamma- 
tion and  irritation,  though  imperceptible,  they  may  follow  and 
even  produce  the  fatal  malady  !  Hence,  the  special  anatomy, 
peculiar  physiology,  and  dangerous  pathology  of  these  parts 
should  be  studied  both  by  students  and  practitioners  with 


PREFACE.  TO 

great  care.  The  writer  has  therefore,  been  at  great  pains  in 
getting  up  a  colored  plate  of  this  hitherto  neglected  anatomy; 
and  also  another  representing  very  finely  the  patho-phjsiog- 
nomy  of  infantile  tetanus.  These  two  original  plates  will 
add  greatly  to  the  value  of  the  work.  The  author  is 
not  aware  that  any  of  this  kind  has  been  heretofore  pub- 
lished. 

Could  the  tetanus  of  adults  be  as  often  traced  to  any  par- 
ticular part  as  that  of  infants  can,  and  were  such  a  part  as 
constantly  liable  to  pass  into  a  morbid  state  at  a  particular 
time,  as  is  the  umbilicus  of  the  child,  its  special  anatomy, 
morbid  changes,  and  time  of  liability  thereunto,  would  be 
most  accurately  and  minutely  described,  demonstrated,  and 
studied  with  a  careful  regard  to  its  great  importance.  Why 
less  important  on  the  part  of  the  infant?  -Merely  because  it 
is  not  generally  understood  and  appreciated.  I  do  not  by 
any  means  charge  the  profession  with  a  disregard  of  infantile 
life,  but  insist  that  this  constant,  palpable  source  of  a  great 
mortality  among  infants  is  not  regarded  by  many  as  it  evi- 
dently should  be.  If  the  real  source  of  this  mortality  was 
generally  known  and  appreciated,  it  would  doubtless  receive 
as  much  careful  attention  as  if  it  appertained  to  adults. 

Besides,  the  profession  has  done  much  by  writing  and 
otherwise  for  the  elucidation  and  cure  of  infantile  diseases. 
Hence,  it  is  more  astonishing  that  the  chief  cause  of  this 
dreadful  and  fatal  disease  has  not  been  more  generally  admit- 
ted, and  proper  and  timely  measures  employed  to  counteract 
it.  This  failure  has  been  highly  prejudicial  to  the  safety  of 
infants  wherever  it  has  prevailed;  for  a  thorough  conviction 


Vlli.  PREFACE. 

of    the    true    cause    of   this    mortal,  affection   would    have 
secured   to   them   a   sure   prophylaxis. 

The  notion,  so  fatal  to  many  infants,  that  Trismus  Nascen- 
tium  is  an  undefined,  nervous  disorder,  having  its  source  in  a 
variety  of  imaginary  causes,  differing  radically  in  its  patho- 
logy from  the  lock-jaw  of  adults,  has  prevented  many  from 
giving  the  navels  of  children  the  protection  which  they  so 
justly  deserve  at  our  hands.  Much  praise  should  be  awarded 
to  those  writers  who  have  called  the  attention  of  practitioners 
to  that  morbid  state  of  the  child's  navel  which  produces  ihe 
tetanus  of  infants,  showing  that  it  is  only  an  infantile  modi- 
fication of  the  traumatic  lock-jaw  of  adults.  But  as  they  have 
not  presented  and  insisted  on  the  only  reliable  prophylaxis,  I 
feel  that  I  am  justifiable  in  publishing, this  volume,  in  order 
that  I  may,  if  possible,  direct  the  attention  of  practitioners 
to,  and  a  solicitous  regard  for,  the  state  of  the  navel,  pending 
the  first  two  weeks  of  infantile  life.  If  proper  measures  be 
then  employed,  children  will  escape  this  disease.  Besides, 
those  writers  who  have  incidentally  written  on  this  subject, 
have  also  written  about  many  Other  things  in  the  same  work — 
things  which  are  generally  more  regarded  than  the  one  which 
I  am  now  trying  to  bring  forward,  in  all  its  exclusive,  weighty 
importance,  more  prominently  before  the  profession. 

Although  we  cannot  cure  this  disease  after  it  is  developed, 
yet  we  can  prevent  it.  We  may  not  be  able  to  expel  the 
enemy  after  he  has  entered  the  house,  yet  in  this  instance  we 
may  bar  the  door  most  effectually  against  him.  A  preven- 
tion will,  however,  require  on  the  part  of  the  practitioner  a 
thorough  conviction  of  the  truth  that,  this  hopeless  malady 


PREFACE.  IX. 

originates  in  a  diseased  condition  of  the  umbilicus,  and  great 
and  unremitting  care  on  his  part  to  prevent  this  state  from 
coming  on,  or  if  it  should,  to  mollify  and  change  it,  during 
the  first  eight  or  ten  days  of  early  life. 

The  writer  has  always  been  very  forward  to  employ  proper 
means  to  prevent  a  diseased  action  of  the  umbilicus  during 
the  separation  of  the  funis  and  a  few  days  afterwards ;  and 
also  for  its  subdual  when  it  occurred.  He  finds  in  his  inter- 
course with  practitioners,  that  he  has  uniformly  on  his  part 
given  more  attention  to  these  things  than  any  physician  with 
whom  he  has  conversed  on  the  subject.  He,  therefore,  feels 
very  confident  that  his  great  and  constant  care  has  given  his 
patients  immunity  from  this  much  dreaded  malady.  He  has 
never  had  a  case  to  occur  in  his  very  extensive  practice  in  an 
infant  of  which  he  had  the  management!  This  remark  was 
made  by  him  eight  years  ago,  when  this  treatise  was  first  pub- 
lished ;  and  he  is  now  happy  in  not  having,  in  any  way,  to 
qualify  it.  May  he  not  then,  most  truthfully  say  that  pre- 
vention is  better  than  cure.  To  prevent  the  occurrence  of  a 
disease  is  much  better,  in  every  sense,  than  to  relieve  it  after 
it  has  occurred,  were  it  in  our  power  to  do  so,  but  when  we 
think  of  its  incurability,  the  prophylactic  treatment  rises,  in 
our  estimation  above  all  other  considerations.  Were  it  even 
occasionally  curable,  the  great  suffering  of  the  little  patient, 
its  doubtful  condition,  the  maternal  anxieties,  so  acutely  felt 
at  such  times,,  are  enough  to  excite  our  greatest  professional 
efforts  to  prevent  it. 

There  is  more  professional  good  and  disinterested  conduct 
practiced  in  preventing,  than  in  curing  a  disease  after  it  has 


X.  PREFACE. 

developed:  much  "suffering,  valuable  time,  painful  anxiety  and 
needful  fees  are  saved  in  that  way.  The  immense  and  incal- 
culable amount  which  has  been  done  by  Prophulaktikos, 
from  the  prevention  of  small-pox  down  to  that  of  a  bad  cold, 
cannot  possibly  fail  to  impress  the  mind  of  the  reader  with 
the  importance  of  this  subject.  The  hand,  though  it  be 
scarcely  seen,  which  from  moral  motives,  or  by  professional 
skill,  wards  off  an  impending  evil,  deserves  far  more  praise 
than  the  one  that,  even  amidst  professional  glare  cures  It 
after  it  has  come.  But  the  statesman  who  by  his  well-timed 
policy  prevents  a  war,  never  acquires  the  renown  of  a  hero 
who  successfully  fights  the  battles  of  one.  So  with  the  doc- 
tor !  Yet  there  are  exceptions  in  both  cases.  Dr.  Jenner 
gained  a  greater  renown  by  his  wonderful  prophylaxis  against 
small-pox  than  any  have  done  by  treating  it.  Although  sani- 
tary measures,  from  quarantine  regulations  down  to  fastidious 
teaching  about  diet  and  dress,  have  been  much  insisted  on, 
yet  for  the  want  of  a  proper  respect  for  them,  they  have 
often  failed  to  do  good.  It  is  very  difficult  to  direct  the  pub- 
lic mind  in  the  proper  ,way  of  prophylaxis.  Hence  the  great 
neglect  of  vaccination,  the  greatest  boon  which  has  ever  been 
conferred  on  mankind  by  scientific  medicine.  In  these  fast 
times  many  are  willing  to  run  the  risk  of  small-pox  rather 
than  stop  to  vaccinate !  The  public  mind  does  not  seem  to 
appreciate  preventives,  and  they  are  often  regarded  as  useless 
hindrances  !  How  can  I  then  hope  for  the  employment  of 
my  prophylactic  ?  What  practitioner  will,  in  his  professional 
hurry,  stop  long  enough  to  manage  the  infantile  umbilicus  as 
he  should  ?     Few  I  fear  !     Yet  this  painful  consideration  does 


PREFACE.  XI. 

not  annul  the  obligations  I  am  under  to  the  profession  and 
to  parents  to  point  it  out,  and  insist  on  its  employment. 

It  is  not  for  the  want  of  professional  magnanimity  that 
these  are  not  employed ;  for  there  is  enough  to  prevent  all 
diseases  were  it  practicable,  either  by  our  administration  of 
them,  or  by  a  general  adoption  of  them  by  the  people.  It  is 
not  of  this  that  I  complain.  It  is  of  too  much  indifference 
about  those  already  known,  both  to  physicians  and  communi- 
ties, especially  of  those  which  may  be  deemed  minor  ones. 
These  have  lost  their  great  importance,  both  in  professional 
estimation  and  general  regard. 

Physicians  have  written  much  on  this  topic,  indeed,  much 
in  point,  but  they  have  not  been  heeded :  those  in  health  will 
not  stop  to  learn  prophylactics  from  the  doctor,  nor  to  employ 
them  when  advised.  Such  essays  have  not  been  written  in 
a  manner  to  impress  the  public  mind  with  their  value, 
nor  do  physicians  themselves  stop  to  advise  and  insist  on 
them  as  they  should.  We  want  a  modern  work  on  this  sub- 
ject ;  few  only  read  old  books.  The  improvements  of  our 
times  are  so  great,  that  many  suppose  things  written  centuries 
ago  can  possess  but  little  value.  Hence,  this  important  sub- 
ject must,  so  to  speak,  be  re-taken  in  hand,  by  some  good  and 
efficient  writer,  and  re-written  for  the  present  time,  and 
thereby  fully  adapted  to  the  spirit,  taste,  and  general  course 
of  things  before  it  will  be  regarded  as  it  should  be.  I  there- 
fore must  be  excused  for  trying,  so  zealously,  to  adapt  the 
one  under  consideration  to  this  state  of  things. 

I  will  now  remind  the  reader  that  my  prophylactic  has  for  its 
object  the  mother's  chief  concern,  her  babe:  which  is  to  her  a 


Xll.  PREFACE. 

moral,  oblivious  anodyne,  causing  her  to  forget  her  past  suf- 
ferings; and  is  also  the  incarnation  of  her  maternal  hopes, 
her  puerperal  joys  and  prospective  delights  which  take  the 
"ways  of  many  agreeable  and  encouraging  fancies.  This,  her 
reward  and  compensation  for  so  much  solicitude  and  suffering, 
must  be  protected,  whereby  her  maternity  may  be  preserved. 
Without  this  living  joy,  what  will  become  of  her?  In  her 
puerperal  state  she  sustains  not  only  a  peculiar  physical  rela- 
tion to  her  offspring,  which  differs  from  all  others,  but  also  a 
sublime  moral  one,  which  also  has  its  peculiarities  in  her 
early  confinement.  At  this  time  she  becomes  almost  one 
with  "her  child.  So  many  of  her  moral  and  physical  feelings 
concenter  in  it  that  she  feels  she  could  not  hope  and  live 
without  it!  "A  new  center  exists,  the  cradle^  around  which 
every  thing  revolves.  The  milky  age,  the  supreme  innocence 
of  the  little  one,  throws  its  spell  over  all.  Compassion  and 
tenderness  enslave  the  family  to  him.  The  father  serves  the 
mother,  and  the  mother  the  child.  It  is  seemingly  a  world, 
ordered  not  like  the  outer  world,  but  according  to  the  law  of 
love,  and  of  God ;  in  it  the  strong  wait  on  the  weak ;  domin- 
ion belongs  to  the  least."  The  mother  will  do  her  part,  and 
shall  the  doctor  fail  to  perform  his  ?  If  he  through  his 
neglect  let  the  child  die,  she  may  die.  This  tender  vine 
entwines  itself  so  closely  around  the  maternal  heart,  pene- 
trating it  at  every  point  with  its  prehensile  embraces  that 
it  cannot  be  removed  without  deep,  dangerous  lacerations. 
Thus  would  her  puerperal  convalescence  be  retarded  or 
decline  into  disease ;  and  how  acutely  painful  would  be  the 
remembrance  of  her  past  travail  !     Says  one,  just  in  point 


PREFACE.  Xlll. 

here :  "  I  have  tears  in  my  heart,  and  for  more  than  one 
thing.  I  have  not  passed  (in  history)  the  Styx,  the  river  of 
the  dead,  so  many  times  with  impunity.  I  am  not  insensible 
to  my  times,  and  I  feel  their  mortal  wounds.  Woll,  all  this, 
which  should  deaden  me  to  private  sorrows,  leaves  a  place  in 
my  heart  plainly  bleeding  for  what  I  have  beheld  so  often, 
the  mother  separated  suddenly  from  her  child." 

When  the  death  of  the  infant  occurs  from  Trismus  it 
most  commonly  occurs  about  the  eighth,  tenth,  or  twelfth  day 
of  the  mother's  confinement.  May  I  not  say  that  this  is  the 
very  worst  time  for  her  to  meet  with  such  a  trying  calamity  ? 
She  has  just  had  time  enough  to  forget  her  sorrows  for  joy 
that  a  child  is  born  unto  her,  and  to  place  all  her  maternal 
affection  on  her  child ;  and  a  little  sore  on  the  navrel  has 
killed  it !  which  the  doctor  might  have  prevented  by  a  timely 
employment  of  the  prophylactic  under  consideration.  Should 
the  like  occur  to  any  physician,  knowing  that  it  might  have 
been  prevented  by  proper  attention  to  the  umbilicus,  how 
shall  he  deal  afterwards  with  his  conscience  and  the  mother's 
sorrow?  Not  by  telling  her  that  it  could  have  been  pre- 
vented, nor  that  it  occurred  by  his  neglect.  That  would 
increase  her  grief  and  ruin  his  professional  character  with 
the  family.  Fortunately,  in  one  sense,  mothers  and  families 
are  ignorant  of  this  means  of  protecting  the  lives  of  infants; 
but  we  hope  the  time  will  come  when  they  will  be  well 
informed  on  this  subject,  and  require  of  their  attendants  a 
faithful  employment  of  this  prophylactic,  even  if  the  attend- 
ing physician  should,  from  a  wrong  theory,  abjure  it.  At  the 
present  time  many  infants  perish  of  this  disease,  that  have 


.XIV.  PREFACE. 

received  no  protecting  treatment  from  the  physicians  who 
attended  their  mothers.  Great,  indeed,  would  be  their  self- 
reproach  were  they  fully  aware  of  the  dreadful  consequences 
of  such  neglect.  No  theory  whatever  of  the  cause  of 
Trismus  should  excuse  him  for  neglect  of  the  child's  umbilicus. 
When  physicians  and  nurses  shall  be  constrained  by  prac- 
tical  results  to  pay  proper  attention  to  the  umbilicus,  then 
but  few  if  any  children  will  die  of  Trismus.  Then  the  great 
object  of  this  work  will  be  accomplished. 

The  reader  must  bear  with  my  great  earnestness  ;  no  luke- 
warm expressions,  no  cold  declarations,  however  truthful  and 
much  in  point,  will  suffice.  For  I  feel  that  I  should  not  only 
state  facts,  but  enforce  them,  also,  by  associating  them  with 
the  moral  considerations  which  should  constrain  us  to  regard 
them  as  duties  incumbent  on  us,  not  only  professionally,  but 
conscientiously.  When  our  moral  feelings  are  properly 
awakened  under  impressive  truths,  we  shall  scarcely  fail  to 
perform  the  duties  which  they  enjoin  on  our  hands  and  bind 
on  our  consciences  !  Let  the  physician  only  look  at  the 
painful  scenes  of  infantile  death  in  the  puerperal  room,  with 
its  moral  and  physical  influence  on  the  bereaved  mother,  the 
sorrow  of  the  father,  and  the  general  distress  of  the  family, 
resulting  from  a  neglect  of  his  duty,  or  that  of  another,  and 
he  cannot  fail  to  appreciate  the  weighty  subject  now  under 
consideration.  These  are  no  idle  fancies,  for  scenes'  of  this 
kind,  enough,  forsooth,  to  move  the  heart  of  stone,  often 
occur  ! 

It  is  well  said,  that  he  who  disregards  truth  in  little 
things   is    very    apt    to    not    regard    it    in    great   things, 


PREFACE.  .XV. 

i 
Nothing   should   be   professionally   small   which   contains   a 

grain  of  practical  truth,  especially  when  infantile  life 
may  be  bound  up  with  it.  Things  may  be  small  in  them- 
selves, and  yet  capable  of  producing  great  results.  The 
hand  which  in  judgment  and  compassion  turns  the  child 
aside  from  the  viper,  may  save  life  by  the  simple  act,  while 
the  one  which  is  withheld  may  destroy  life.  Thus  we  see 
that'  both  positive  and  negative  evils,  however  great  in  them- 
selves, may  be  occasioned  by  very  little  things. 

Thus  I  have  labored  to  raise  my  prophylactics  prospec- 
tively, in  the  estimation  of  the  reader,  that  he  may  not  un- 
dervalue them  because  they  may,  in  ignorance,  be  called 
little  things. 

After  all,  did  these  simple  means,  called  ina  this  treatise 
prophylactics,  require  great  mental  effort  to  obtain  a  know- 
ledge of  them,  great  surgical  or  clinical  tact  to  employ 
them,  and  great  confidence  to  admit  of  their  employment, 
they  would  be  more  highly  respected  and  more  constantly 
practiced.  As  they  are  capable  of  doing  as  much  or  even 
more  general  good  than  if  they  were  of  the  character  just 
stated,  why  should  they  not,  in  point  of  utility,  at  least,  be 
equally  respected  and  as  constantly  employed  ?  No  good 
reason  can  be  assigned.  Professional  pride  may  murmur  and 
hint  that  it  cannot  stoop  to  such  little  things.  He  who  can- 
not stoop  professionally  to  save  life,  can  never  stand  consci- 
entiously erect  in  his  profession.  It  is  a  profession  which 
has  much  to  do  with  the  conscience  of  the  practitioner  as 
well  as  with  the  lives  of  patients.  Hence,  nothing  in  the 
estimation  of  the  true  physician  can  be  small  which  secures 


XVI.  PREFACE. 

life.  Lastly  —  can  anything  however  apparently  little 
in  itself,  be  considered  trifling  or  small  in  the  esti- 
mation of  a  bereaved  family,  which  they  knew  would  have 
saved  the  life  of  the  child  that  was  destroyed  by  tetanus  the 
day  before  ?  Our  negative  answer  here  should  bind  us  to 
our  duty,  which  we  should  constantly  perform  though  it  may 
lead  us  in  the  way  of  little  things,  as  some  in  the  blindness 
of  professional  pride  have  termed  them.  Pride  constantly 
stands  in  the  way  of  the  performance  of  some  of  our  greatest 
duties,  and  often  requires  for  its  correction  and  subdual,  the 
exercise  of  great  moral  courage.  And  he  who  has  not  a 
sufficient  amount  thereof  firmly  and  indignantly  to  meet  the 
taunts  and  jeers  of  the  ignorant  or  the  proud  in  regard  to  his 
means  of  saving  life,  is  not  worthy  of  the  confidence  of  any 
community.  Let  the  young  practitioner  not  be  afraid  or 
ashamed  to  employ  useful  prophylactics,  let  them  be  regarded 
in  whatever  light  they  may  be  by  others. 


TRISMUS  NASCENTIUM, 

ITS  HISTORY,  ETIOLOGY  AND  PROPHYLAXIS. 


This  great  outlet  of  infantile  life  has  not  received  that 
notice  and  investigation  from  our  best  writers,  which  its 
great  importance  so  justly  merits:- — some  passing  it  by 
in  reprehensible  silence,  have  written  copiously  enough 
on  other  opprobia  medicorum,  while  others  have  given  us 
only  a  few  formal  pages  or  paragraphs  on  a  subject  which 
required  at  their  hands  a  most  elaborate  treatise.  All  that 
has  been  published  about  this  fatal  malady,  is,  for  the  rqpst 
part,  well  calculated  to  embarrass  and  disappoint  the  reader 
— leaving  him  uninformed  of  its  history,  in  doubt  about 
its  etiology,  and  uninstructed  in  a  reliable  prophylaxis — 
not  remedy,  for  there  is  none ! 

Moschion,  who  wrote  a  manual  of  midwifery  about  the 
end  of  the  first  century,  entertained  an  opinion  vaguely 
correct  in  regard  to  the  exciting  cause  of  this  disease ;  so 
did  Levret.  They  thought  that  the  stagnant  blood  in  the 
umbilical  cord  might  produce  dangerous  disease ;  probably 
they  had  seen  this  malady  consequent  upon  inflammation 
and  irritation  of  the  navel.  M.  Bajon  also  concurred  in 
this  opinion,  distinctly  regarding  a  pathological  condition 


of  the  umbilicus  as  the  cause  of  this  affection — a  view 
which  Dr.  Colles  has  very  nearly  confirmed  by  his.  dissec- 
tions and  observations.  It  has,  however,  been  attributed 
to  very  different  causes  by  Evans,  Bartram,  Clark,  Under- 
wood, Labatt  and  others.  Hence,  we  meet  with  a  great 
contrariety  of  opinion,  as  expressed  by  those  writers — all 
disagreeing  in  their  etiological  expositions,  indeed,  so  much 
so,  as  greatly  to  impair  our  confidence  in  their  writings. 

Dr.  Cullen,  a  copious  writer  on  other  subjects,  has  treated 
the  one  under  consideration  with  great  brevity ;  conscious 
of  his  apparent  neglect,  he  says  apologetically :  "  It  is  a 
disease  that  has  been  almost  constantly  fatal,  and  this, 
also,  commonly  in  the  course  of  a.  few  days.  The  women 
are  so  much  persuaded  of  its  inevitable  fatality,  that  they 
seldom  or  ever  call  for  the  assistance  of  our  art.  This  has 
occasioned  our  being  little  acquainted  with  the  history  of 
the  disease,  or  with  the  effects  of  remedies  in  it."  But 
this  is  not  the  secret ;  physicians  had  seen  this  disease 
often  enough,  but  did  not  understand  it ;  they  had  also 
treated  it,  but  had  not  cured  it ;  had  sought  out  its  cause 
and  pathology,  but  had  not  found  them ;  hence,  forsooth, 
so  many  writers  have  avoided  the  great  difficulties  involved 
in  its  obscure  history,  controverted  etiology,  unknown 
pathology  and  intractable  course.  Colley,  Condie,  Church- 
hill,  and  others,  though  greatly  skilled  in  eclecticism,  have 
gathered  but  little  valuable  or  satisfactory  information  from 
the  writings  of  others  on  this  subject.  Journalists,  know- 
ing that  systematic  writers  have  failed  to  account  for  the 
phenomena  of  this  disease,  and  being  unrestrained  by  any 
known  facts,  have  propagated,  and  vainly  attempted,  by 


reporting  cases,  to  prove,  many  fanciful  and  untenable 
conjectures.  To  a  particular  instance  of  this  kind,  I  will 
now  refer : 

Dr.  J.  Marion  Sims,  of  Montgomery,  Alabama,  has  pub- 
lished in  the  Medical  Journal  of  the  Medical  Sciences  some 
interesting  "Observations  on  Trismus  Nascentium,  with 
cases  illustrating  its  etiology  and  treatment."  From  all 
of  which  he  deduces  the  following  strange  and  unwarrant- 
able conclusions :  "  That  Trismus  Nascentium  is  a  disease 
of  centric  origin,  depending  upon  a  mechanical  pressure, 
exerted  on  the  medulla  oblongata  and  its  nerves ;  that  this 
pressure  is  the  result,  most  generally,  of  an  inward  dis- 
placement of  the  occipital  bone,  often  very  perceptible,  but 
sometimes  so  slight  as  to  be  detected  with  difficulty ;  that 
this  displaced  condition  of  the  occiput  is  one  of  the  fixed 
physiological  laws  of  the  parturient  state ;  that  when  it 
persits  for  any  length  of  time  after  birth,  it  becomes  a 
pathological  condition,  capable  of  producing  all  the  symp- 
toms of  Trismus  Nascentium,  which  are  instantly  relieved 
simply  by  rectifying  this  abnormal  displacement,  and  there- 
by removing  the  pressure  from  the  base  of  the  brain." 

I  have  made  this  lengthy  quotation  in  justice  to  Dr. 
Sims,  as  I  intend  to  make  some  critical  remarks  on  his 
observations,  cases  and  conclusions.  I  will  endeavor  to  do 
this  fairly  at  least,  yet  faithfully  His  strange  views, 
wonderful  practice,  and  doubtful  cases,  require  a  very  rigid 
examination \  which,  when  fairly  and  faithfully  made,  may 
seem  a  little  severe;  therefore,  I  will  here  remark,  that 
nothing  like.wanton  severity  is  intended ;  on  the  contrary, 
I  am  ready  to  acknowledge  his  merits  as  an  independent 


thinker  and  actor,  by  which,  great  difficulties  have  some- 
times been  overcome,  at  other  times  signal  failures  have 
ensued.  The  latter  sequence  has  followed  in  the  present 
instance.  The  Doctor  has  failed  in  his  commendable  enter- 
prise ;  but  his  failure  is  a  splendid  one !  Had  he  succeeded 
in  directing  one  ray  of  light  into  the  deep,  dark  plasis  of 
this  mortifer  morbus,  he  would  have  merited  the  everlast- 
ing gratitude  of  the  profession.  Signal  as  his  failure  has 
been,  judging  from  his  writings,  he  does  not  seem  to  be 
conscious  of  it;  but  on  the  contrary,  contends  that  he  has 
succeeded  in  finding  out  the  etiology  of  this  disease,  and 
for  it,  also  a  remedy  !  The  occasional  displacement  of  the 
cranial  bones  is  a  subject  to  which  the  attention  of  prac- 
titioners of  medicine  should  be  directed ;  but  while  we  feel 
under  great  obligations  to  Dr.  Sims  for  calling  our  atten- 
tion to  this  source  of  disease,  we  are  far  from  admitting 
that  it  is  ever  a  cause  of  Trismus,  be  it  the  source  of  what- 
ever other  affections  it  may. 

The  Doctor  has  investigated  this  subject  according  to 
the  following ■" fixed  ideas :"  1.  Dorsal  decubitus;  2.  Oc- 
cipital depression  ;  3.  Trismus  Nascentium  ;  4.  Chang*  of 
position;  5.  Recovery.  These  five  things  always  obtain 
in  the  mind  of  Dr.  S.  whether  they  do  in  his  patients  or 
not ;  when,  for  instance,  they  cannot  be  seen  *by  other 
physicians,  he  seems  to  recognize  them  none  the  less  clear- 
ly, as  we  shall  discover  presently. 

His  case  the  II  presents  the  following  particulars  :  The 
patient  had  been  ill  of  Trismus  Nascentium  two  days — the 
attending  physician,  had  declared  that  the  disease  was  in- 
flammation of  the  brain,  and  that  death  was  inevitable — 


there  were  frequent  spasms — mouth  closed  tightly — swal- 
lowing impossible — the  back  of  the  head  sunk  in.  A 
change  of  position  was  made,  which  in  four  hours  gave 
relief,  and  in  eighteen  hours  cured  the  disease  !  All  this 
was  done,  too,  without  the  aid  of  homoeopathy,  hydropathy, 
or  mysticism  of  any  kind.     0  pathetism,  where  wert  thou ! 

In  this  case  the  depressed  occiput  was  relieved  by  a 
mere  change  of  position,  and  the  patient  cured  in  eighteen 
hours.  How  shall  we  reconcile  these  statements  ?  A  case 
of  Trismus  Nascentium,  presenting  the  foregoing  array  of 
symptoms,  of  two  days  continuance — the  patient  just 
ready  to  die,  and  then  cured  by  a  mere  change  of  position 
in  eighteen  hours ! 

To  the  credit  of  Dr.  Sims  I  will  here  state  that  this  case 
was  obtained  from  a  non-medical  correspondent ;  although 
he  has  endorsed  it,  yet  I  am  willing  he  should  have  all  the 
benefit  of  the  foregoing  fact. 

The  very  next  case,  however,  is  both  marvelous  and  in- 
consistent, although  reported  by  the  Doctor  himself:  The 
child  "  was  born  trismal,"  had  had  the  disease  thirty-six 
hours  when  seen  by  him,  then  by  his  magic  change  of  posi- 
tion was  cured  in  two  hours  ! 

His  statements  in  case  the  IV,  in  regard  to  the  symptom 
of  the  child's  inability  to  suck,  do  not  accord  with  my  own 
observations.  "  This  inability  to  sack,''  says  he,  "is  path- 
ognomonic of  the  disease."  This  symptom  does  not  always 
exist  in  the  tetanus  of  children,  especially  in  that  variety 
termed  chronic :  this  inability  to  swallow  may  be  absent 
just  as  it  is  sometimes  in  the  tetanus  of  adults.  I  have 
seen  fatal  cases  of  infantile  tetanus,  when  the  symptom  of 


8 

trismus  did  not  obtain — there  was  rather  a  disinclination 
than  an  inability  to  suck.  But  if  he  supposes  that  the 
mere  symptom  of  trismus  constitutes  the  whole  of  the 
disease,  then  is  he  correct  in  saying  that  u  an  inability  to 
suck  is  pathognomonic  of  the  disease."  Let  his  views  be 
what  they  may  in  this  respect,  there  would  be  no  less  im- 
propriety in  saying  that  the  varieties  of  the  opisthotonos 
and  emprosthotonos  are  not  tetanus  in  the  strict  sense  of 
that  term,  than  to  conclude  that  trismus,  another  variety, 
is  not.  This  reminds  me  of  Dr.  Cullen's  acknowledgment : 
"  I  have  in  my  nosology  put  the  trismus  or  locked  jaw,  as 
a  genus  distinct  from  the  tetanus ;  all  this,  however,  I  now 
judge  to  be  improper,  and  am  of  opinion,  that  all  the  gen- 
eral terms  mentioned  denote  and  are  only  applicable  to 
different  degrees  of  one  and  the  same  disease."  Surely 
trismus  in  the  infant  or  adult,  is  a  mere  variety  of  tetanus, 
and  like  the  other  varieties  depend  upon  a  pathological 
condition  of  some  of  the  cerebro-spinal  centres. 

It  is  a  great  misfortune  that  the  term  trismus  nascentium 
was  ever  adopted  \  tetanus  nascentium  would  have  been  a 
better,  though  a  less  euphonious  one.  There  was  no  great- 
er necessity  for  changing  the  name  of  this  disease  in  the 
case  of  infants  than  there  is  to  change  that  of  pneumonia, 
dysentery,  or  colic,  when  they  attack  children.  We  had 
just  as  well  term  tetanus,  trismus  adultorum,  trismus  viro- 
rum,  or  trismus  feminarum,  as  to  call  it  trismus  nascenti- 
um. In  the  employment  of  these  terms,  that  of  tetanus, 
would  be  kept  too  much  in  the  back  ground,  as  it  really 
has  been,  by  the  use  of  the  term  trismus  nascentium.  Like 
Dr.  Sims,  we  may  lose  sight  of  the  true  character  of  a 


tetano — pathological  condition  of  some  portion  of  the 
cerebro-spinal  column,  which  in  every  instance  is  the  prox- 
imate cause  of  the  disease ;  and  which  cannot  be  relieved 
in  a  moment  in  any  instance,  and  often  not  at  all,  by  a 
mere  removal  of  the  exciting  cause.  This  every  careful 
observer  knows ;  but  more  of  this  presently. 

I  will  now  examine  case  the  V,  being  the  most  remark- 
able the  Doctor  ever  saw.  This  case  was  reported  in  part 
by  a  Dr.  Vickers,  though  seen  and  commented  on  by  Dr. 
S.  himself.  The  child  was  four  or  five  months  old' — had 
been  sick  all  its  life — the  occipital  bone  was  shoved  in  to 
an  almost  incredible  extent — it  had  trismal  symptoms,  ac- 
cording to  his  estimation  of  them,  which  were  completely 
under  the  control  of  the  Doctors ;  they  were  relieved  and 
reproduced  at  pleasure  by  simply  rectifying  and  displacing 
the  occiput.  This  was  done  according  to  Dr.  Sims'  pre- 
vious proposition,  "  That  the  symptoms  of  Trismus  Na~ 
scentium  are  instantly  relieved  by  simply  rectifying  the 
abnormal  displacement  of  the  occipital  bone."  This  is  one 
of  his  propositions  deduced  from  his  cases  and  observations, 
and  put  down  in  his  treatise  in  all  due  form. 

Who  except  Dr.  Sims  could  thus  have  hooked  the  Levi- 
athan, and  led  the  monster  to  and  fro  with  such  trismal 
docility  !  No  one,  alas !  Surely  he  had  only  the  pliant 
dolphin  clonus  with  which  to  deal,  and  not  the  crooked 
serpent  tetanus.  That  alternate  displacement  and  replace- 
ment of  the  occiput  should  suspend  and  reproduce  some 
particular  forms  of  paralysis,  or  nervous  affections,  I  an i 
prepared  to  admit ;  but  that  trismus,  after  being  established 
for  days,  or  even  hours,  should  be  thus  dealt  with,  is  more- 


10 

than  any  physician  who  clearly  distinguishes  this  disease 
from  other  nervous  disorders,  can  allow,  in  my  humble 
judgment.  The  symptoms  of  trismus  may  be  excited — 
not  cured — by  rubbing  the  epigastrium,  which  I  have  my- 
self often  done  in  obscure  cases,  to  develop  the  symptoms 
more  fully ;  afterwards  there  would  be  a  reduction  of  the 
former  symptoms,  from  the  expenditure  of  nervous  excita- 
bility. The  same  occurred  also,  I  presume,  in  the  Doctor's 
cases  of  nervous  disorders,  by  raising  and  depressing  the 
cranial  bones. 

I  shall  not  follow  Dr.  Sims  through  his  trismoid  cases, 
as  he  terms  them ;  those  already  mentioned  are  surely  tris- 
moid  enough,  in  that  diminutive  sense,  so  much  so  in- 
deed, that  even  such  a  term  is  too  strong  for  them.  Be- 
sides, I  did  not  intend  to  review  his  writings  in  a  regular 
way,  yet  there  are  a  few  things  connected  with  these  tris- 
moid cases,  which  I  will  notice. 

Dr.  S.  has  reported  but  one  case  of  cadaveric  autopsy, 
and  strange  to  relate,  this  does  not  contain  a  single  word 
about  lesion  of  the  brain  or  meninges,  from  a  long  contin- 
ued displacement  of  the  cranial  bones — only  that  the 
u  brain  was  perfectly  bloodless" — no  signs  of  previous  con- 
gestion, irritation  or  inflammation. 

When  the  Doctor  could  not  make  out  a  case  of  dorsal 
decubitus  and  depression  of  the  occipital  bone,  still  cling- 
ing to  his  fixed  idea,  or  cherished  theory,  he  learned  that 
the  child  had  been  nursed  on  its  side,  and  that  lateral,  or 
rather  diagonal  decubitus  had  produced  a  depression  of  a 
pariental  bone,  and  laying  hold  of  this  opportune  succeda- 


11 

neuin,  he  maintains  his  views  with  as  much  confidence  as 
before. 

If  any  thing  was  still  wanting  to  show  that  Dr.  S.  does 
not  appreciate  the  danger  and  mortality  of  this  dreadful 
disease,  I  might  advert  to  his  notions  about  the  operation 
of  laryngotomy  affording  relief  until  it  could  be  cured.  I 
will  not,  however,  detain  the  reader  longer  with  any  further 
critical  remarks  on  this  subject,  but  advise  him  to  read  the 
treatise  for  himself,  which  he  may  find  in  the  American 
Journal  of  the  Medical  Sciences,  in  April  number,  1846, 
and  in  July  and  October  numbers  of  1848.  If  any  fur- 
ther apology  be  necessary  for  these  strictures  it  may  be 
found  in  the  remark,  that  Dr.  S.'s  theory,  cases  and  treat- 
ment are  all  well  calculated  to  mislead  the  inexperienced 
and  divert  their  minds  from  the  true  sources  .of  tetanus, 
and  also  from  the  only  means  by  which  infants  can  be  pro- 
tected against  an  often  occuring  and  incurable  malady. 

I  will  now  take  my  leave  of  the  Doctor  in  ihe  words  of 
Petrarch:  "Raro  magni  errores  nisi  ex  magnis  ingeniis 
prodiere. 

Etiology. — The  causes  of  Trismus  Nascentium  with 
their  attendant  difficulties,  like  every  thing  else  pertaining 
to  this  perplexing  malady,  have  been  very  much  neglected : 
indeed,  I  am  not  aware  that  any  writer  has  arranged  them 
according  to  their  proper  relation  to  each  other,  or  their 
usual  division  in  other  diseases.  Its  predisponent,  exciting, 
and  proximate  causes  have  often  been  confounded  with 
each  other — one  writer  mistaking  the  predisponent  for  the 
exciting  cause,  and  another,  the  latter  for  the  former.     It 


12 

will  be  readily  conceded  that  these  causes  occasionally 
change  their  relation  to  each  other,  but  this  is  very  differ- 
ent from  confounding  them  with  each  other  in  particular 
instances.  While  treating  this  subject  according  to  the 
foregoing  division,  I  shall  have  occasionally  to  introduce 
other  causes  in  their  proper  places,  such  as  accidental,  ac- 
cessory, &c. 

It  will  be  necessary  to  make  a  clear  distinction  between 
the  predisponent  cause  and  the  habit  of  body  or  diathesis, 
which  constitutes  the  predisposition  itself.  Two  persons, 
for  instance,  may  be  exposed  to  the  same  predisponent 
causes,  and  in  one  a  predisposition  to  a  particular  disease 
may  be  produced  by  the  yielding  susceptibilities  of  his 
system,  and  be  resisted  by  the  opposing  energies  of  the 
other ;  or  the  same  person  may  be  affected  by  such  causes 
at  one  period  and  escape  their  influences  at  another. 
Again,  a  predisposition  to  a  disease  may  exist  as.  a  connate 
diathesis.  Then  let  a  predisposition  to  tetanus  be  the  effect 
of  whatever  predisponent  causes  it  may,  it  must  be  regard- 
ed as  a  pathological  state;  which  though  occult  and  unap- 
preciable  by  any  pathognomonic  symptoms,  yet  it  is  doubt- 
less a  tetanic  element,  capable  of  being  developed  by  an 
exciting  cause  into  plain,  open,  unmistakable  symptoms  of 
lock  jaw,  or  of  being  subdued  by  a  proper  prophylaxis, 
which  consists  mainly  in  a  protection  from  exciting  causes. 
The  agency  of  an  exciting  cause,  however  potent  and  ac- 
tive it  may  be,  fails  to  produce  the  disease,  when  there  is 
no  existing  predisposition,  as  may  be  illustrated  by  the  fol- 
lowing examples :  Two  persons  of  the  same  age,  sex,  tem- 
perament and   habits,   breathing  the   same  atmosphere, 


13 

receive  similar  wounds  in  corresponding  situations ;  one  is 
attacked  with  tetanus,  and  the  other  escapes ;  or,  an  indi- 
vidual receives  a  very  bad  wound  and  escapes  lock  jaw, 
and  is  afterwards  attacked  with  it  from  a  very  slight  wound. 
Such  instances  certainly  show  that  the  disease  does  not  de- 
pend alone  on  an  exciting  cause.  Again,  the  terminal 
points  of  wounded  nerves  may  pass  into  a  tetano-patholog- 
ical  condition  in  a  slight  wound,  and  not  in  a  far  greater 
one,  and  vice  versa.  So,  it  is  not  the  situation  or  size  of 
a  wound  which  determines  an  attack  of  this  disease,  but  a 
peculiar  occult  state  of  the  general  system.  This  condi- 
tion may  not,  however,  amount  to  a  direct  tetanic  tenden- 
cy, but  may  be  only  a  mere  vitiation  of  the  system  that 
may  interfere  with  the  healthy  healing  of  the  wound,  or 
the  formation  of  a  sound  cicatrix;  for  the  simple  healing- 
over  of  a  wound  does  not  afford  protection  from  an  attack 
of  this  fatal  malady,  neither  in  infants  nor  adults.  Then, 
any  thing  which  impairs  health  in  manhood  or  infancy 
may,  in  this  general  way  act  as  a  predisponent  cause  of 
tetanus ;  but,  'there  are  some  particular  causes  which  evi- 
dently exert  a  more  direct  predisposing  influence,  such  as 
cold,  impure  air,  a  damp,  cold  atmosphere,  indigestion  and 
high  solar  heat.  And  why  may  not  malaria,  itself,  the 
frequent  and  great  source  of  so  many  maladies,  impress 
the  system  with  a  strong  tetanic  predisposition,  by  pro- 
ducing cerebro-spinal  irritation,  or  irritation  of  some  of  the 
other  great  ganglionic  nervous  centres.  This  opinion  is 
confirmed  by  the  fact  of  Trismus  having  occurred  so  fre- 
quently in  foul  and  badly  ventilated  lying-in-hospitals,  and 
its  occurrence  having  been  prevented  by  improvements  for 


14 

ventilation  and  cleanliness  in  such  institutions,  as,  for  in- 
stance, in  the  Dublin  lying-in  hospital.  Dr.  Joseph  Clarke's 
account  of  this  institution,  in  reference  to  the  foregoing, 
is  conclusive  on  this  subject. 

The  Exciting  Cause  of  Tetanus  Nascentium. — A  trauma- 
tico-tetanic  condition  of  the  umbilicus  is,  with  very  few 
exceptions,  the  constant  exciting  cause  of  this  disease. 
This  part  of  my  subject  I  shall  now  discuss  at  great  length 
as  it  is  paramount  in  importance  to  all  others,  in  a  prac- 
tical point  of  view.  The  analogy  between  traumatic 
tetanus,  as  it  occurs  in  the  adult  and  infant,  is  both  stri- 
king and  instructive,  and  well  deserves  our  most  particular 
consideration.  In  the  adult,  this  disease  generally  comes 
on  about  the  eighth  or  ninth  day  after  the  reception  of  a 
wound,  and  in  the  infant,  it  attacks  so  frequently  on  the 
ninth  day  after  the  cutting  of  the  funis,  that  it  has  been 
termed  "nine-day  fits."  That  portion  of  the  cord  which, 
after  its  division  is  left  in  connection  with  the  navel,  is  as 
liable  to  degenerate  into  an  exciting  cause  of  tetanus  in 
the  infant,  as  is  a  common  wound  in  the  adult.  The  beauti- 
ful physiological  process  of  desiccation,  contraction  and 
separation  of  the  cord  so  seldom  occurs  that  it  has  been 
disregarded  by  many  eminent  writers.  Even  the  great 
Baron  Albert  Yon  Haller  says :  "  Funiculi  quidem  ombili- 
calis  particula  quam  obstetrics  solent  cum  abdomine  parvuli 
conjunctam  relinquere  abit  in  sphacelam,  quassi  ambusta 
et  post  biduum,  triduumve  dilabitur."  This  is  certainly  a 
good  pathologcid,  though  by  no  means  a  physiological  de- 
scription of  the  separation  of  the  funis — a  traumatic  state 


15 

of  things  however,  which  frequently  occurs.  This  over- 
sight has  been  committed  also  by  other  distinguished 
writers,  namely,  Chaussier,  Beclard,  Orfila,  Capuron,  and 
Dennis. 

C.  M.  Billard's  explanation  of  the  separation  of  the  funis 
is  quite  satisfactory.  He  very  properly  maintains  that 
u  the  desiccation  of  the  cord  is  altogether  a  physiological 
phenomenon,  belonging  to  the  assemblage  of  vital  phenom- 
enon, and  entirely  dependent  on  them.  That  part  of  the 
cord  attached  to  the  placenta  does  not  exhibit  the  phenom- 
enon of  desiccation,  like  the  portion  remaining  with  the 
child,  but  shrinks  and  decays  like  a  dead  substance,  whilst 
the  abdominal  portion  is  not  so  affected.  Here  the  desic- 
cation ceases  as  soon  as  life  is  extinct ;  it  either  does  not 
proceed  in  still-born  children,  or  is  considerably  retarded. 
In  place  of  drying  and  separating  at  the  end  of  a  few  days, 
as  is  observed  during  life,  the  cord  undergoes  in  the  dead 
body  a  perfect  decomposition,  differing  entirely  from  its 
normal  desiccation."  He  further  contends  that  the  umbil- 
ical cord  may,  under  favorable  circumstances,  separate  from 
the  navel,  just  as  the  stem  of  a  cucurbitaceous  fruit  is  sep- 
arated, or  by  what  he  terms  "a  proper  suppuration." 
Of  eighty-six  infants  examined  by  him,  nineteen  had  red- 
ness and  tumefaction  of  the  umbilicus,  without  suppuration. 
The  period  of  the  detachment  of  the  cord  varies  from  the 
second  to  the  seventh  day. 

The  infrequency  of  the  healthy  normal  separation  of  the 
funis  has  not  only  been  greatly  overlooked  by  writers,  but 
shows  likewise  how  very  liable  infants  are  to  irritaiton,  in- 
flammation and  sloughing  of  that  portion  of  it  which  is  left 


'    16 

at  birth  attached  to  the  abdomen.  This  degeneration  of  a 
healthy  vital  action  into  a  morbid,  abnormal  one,  is  easily 
induced  by  a  great  variety  of  causes,  to  all  of  which  some 
children  are  more  exposed  than  others,  and  among  such 
tetanus  is  of  far  more  frequent  occurrence.  These  common 
causes  among  the  blacks  are  bad  dressings  of  the  umbilicus, 
improper  handling  of  the  infant,  wet  and  soiled  dressings, 
which  become  alternately  wet  and  dry  for  several  days ;  to 
•which  may  be  added  unsuitable  applications  to  the  naval 
itself  after  the  detachment  of  the  cord,  that  are  more  cal- 
culated to  irritate  and  inflame  the  part,  and  in  that  way  to 
provoke  lock  jaw,  than  to  soothe,  heal  and  prevent  its 
supervention. 

As  there  is  a  much  greater  difference  in  the  manage- 
ment, comforts  and  habits  between  white  and  black  women 
after  their  confinement,  than  in  their  parturition,  the  causes 
which  operate  on  the  children  of  the  latter,  in  occasioning 
a  greater  frequency  of  this  disease  among  them,  must  occur 
after  birth ;  besides  it  is  well  known  that  the  negro  women 
generally  have  safer  and  easier  labors  than  white  women, 
as  a  consequence  of  their  active,  laborious  habits.  Hence, 
neither  the  imaginary-  concussion  of  the  spine  during  de- 
livery, nor  the  vaunted  displacement  of  the  occipital  bone 
consequent  upon  dorsal  decubitus,  does  account  for  the 
very  great  amount  of  numerical  difference  between  the  at- 
tacks of  white  and  colored  children.  This  difference  must 
be  occasioned  by  some  particular  causes,  both  predisponent 
and  exciting,  very  different  from  those  to  which  I  have 
just  adverted. 

I  will  now  present  an  arrangement  of  facts,  from  which 


17 

an  opinion  of  the  utmost  practical  importance  may  be  de- 
duced, in  regard  to  the  exciting  eause  of  this  disease — an 
opinion  which  when  entertained  must  exert  a  salutary 
influence  in  checking  the  dreadful  outbreaking  of  this 
intractable  morbus.  That  this  opinion  may  be  embraced 
and  have  its  proper  practical  influence,  is  one  of  the  chief 
objects  of  the  writer  in  contending  for  it  so  earnestly ; 
which  is  done  not  merely  to  confirm  the  fact  as  he  believes, 
that  a  diseased  umbilicus  is  the  cause  of  infantile  tetanus, 
but  that  a  safe  and  easy  prophylaxis  may  be  established 
on  a  reliable  basis,  not  to  be  overturned  by  a  constant 
failure  of  the  remedy  in  the  hands  of  others,  as  has  unfor- 
tunately been  the  case  with  most  of  those  means  prescribed 
by  others  in  accordance  with  their  peculiar  theories.  Their 
is,  however,  one  just  exception  to  this  remark,  which  de- 
serves to  be  mentioned :  Dr.  Joseph  Clark  and  others,  re- 
garding badly  ventilated  lying-in  hospitals,  with  their  bad 
air  and  filthy  apartments  as  causes  of  this  malady,  have 
done  much  good  by  their  accordant  prophylactic  directions. 
For,  although  they  mistook  the  predisposing  for  the  ex^ 
citing  cause,  yet  by  directing  that  such  causes  should  be 
avoided  and  corrected,  the  exciting  cause,  which  is  now  so 
zealously  contended  for,  though  present  and  active  in 
many  instances,  was  in  others  greatly  deprived  of  it* 
tetanic  influence. 

Suppose  Dr.  Clark  had  said  in  regard  to  wounded 
patients  in  a  hospital,  that  a  vitiated  atmosphere  was  the 
exciting  cause  of  tetanus  among  them,  and  that  their 
attacks  of  this  disease  were  due  to  a  state  of  the  atmos- 
phere, and  not  their  wounds.  He  could  scarcely  hare 
2 


18 

committed  a  worse  blunder  than  he  has  done  by  writing 
that  tetanus  was  excited  by  bad  air  in  the  lying-in  estab- 
lishment of  which  he  had  charge,  instead  of  the  tetanic 
condition  of  the  navels  of  the  children. 

That  the  Exciting  Cause  of  this  disease  may 'be  plainly 
seen  and  practically  regarded,  I  will  now  set  in  order  a 
number  of  facts,  both  in  their  proper  relation  to  each  other 
and  their  general  bearing  on  its  controverted  points.  From 
these,  surely,  a  safe  and  useful  conclusion  may  be  easily 
deduced.  By  an  arrangement  of  even  dim  lights  in  a 
proper  manner,  we  may  discern  an  object  which  could  not 
otherwise  be  seen  by  them,  so  in  the  present  instance  by 
a  proper  collation  of  facts  we  may  obtain  a  more  correct 
view  of  the  exciting  cause  of  tetanus  nascentium. 

The  infant  is  no  sooner  born  than  it  becomes  a  irau- 
matiaSy  a  trauma  must  of  necessity  be  inflicted  on  its  um- 
bilical cord ;  a  wound  on  a  part  which  is,  as  has  already 
been  shown  in  the  first  part  of  this  treatise,  so  very  prone 
to  pass  into  a  pathological  condition,  and  thereby  excite 
irritation  and  inflammation  of  the  umbilicus,  that  many 
eminent  writers  have  overlooked  its  physiological  excep- 
tions. With  the  brute  mammalia,  this  artificial  division 
of  the  cord  is  unnecessary,  as  theirs  break  according  to  an 
appropriate  physical  state ;  then  dry,  contract  and  fall  off 
without  producing  inflammation  of  their  navels.  Hence, 
though  a  species  of  the  equus  genus  of  animals  is,  as  is 
well  known,  very  liable  to  tetanus  from  wounds  and 
other  causes,  yet  no  one,  I  presume,  ever  saw  their  foals 
suffering  from  the  disease;  as  the  horse  is  thus  man's 
*?tf#w-congener,  might  we  not  expect  to  see  them  attacked 


19 


also  occasionally  with  this  disease  I  As  adults  and  horses 
are,  in  this  particular  respect,  pathologically  congeneric, 
why  should  we  suppose  that  their  offspring  are  not  so  like- 
w  ise  ?  It  is  quite  reasonable  to  believe  that  they  are,  and 
that  the  immunity  of  colts  from  the  disease  is  not  owing 
to  any  connate  difference  of  that  kind,  but  to  an  exemption 
from  its  exciting  cause — irritation  and  inflammation  of 
their  navels.  The  experiment  of  exciting  artificial  inflam- 
mation of  the  navels  of  the  equinal  young  might  shed 
some  light  on  this  subject.  I  will  here  remark  that  it  is 
not  contended  that  the  bare  wound  on  the  part  of  the  cord 
left  attached  to  the  child's  abdomen,  causes  a  pathological 
condition  of  that  part,  but  the  state  itself  of  the  part  is 
such  as  to  admit  of  an  easy  perversion  of  its  normal  pro- 
cess of  separation,  in  which  particular,  it  differs  very  much 
from  the  navel  strings  of  other  animals.  The  infantile 
umbilical  cord,  is  too  strong  to  be  thus  safely  broken,  and 
too  full  of  the  gelatine  of  Wharton  to  dry,  contract  and 
fall  off  in  the  equinal  way ;  it,  therefore,  requires  some 
rational  management.  Really,  it  seems  to  have  been  de- 
signed by  the  Great  Giver  of  mind,  that  the  infant  should 
not  only  receive  instinctive,  but  likewise  rational  protec- 
tion at  our  hands.  So,  when  their  navel  strings  are  man- 
aged in  a  rational  way,  they  will  not  induce  irritation  nor 
inflammation  of  the  umbilicus.  It  is  necessary  then  that 
the  cord  should  be  cut,  and  other  appliances  be  employed, 
of  which  I  shall  treat  more  fully  presently.  I  must,  how- 
ever, repeat 'that  the  navels  of  children,  from  bad  manage- 
ment and  other  causes,  often  become  inflamed,  and  it  is  a 
fact  of  no  small  consequence  that  negro  children  are  far 


20 

more  liable,  to  a  variety  of  accidental  or  accessory  causes^ 
which  occasion  irritation  and  inflammation  of  the  umbili- 
cus, and  it  is  well  known  that  they  are  also  more  liable  to 
tetanus.     This  liability  to  trismus  is  in  a  very  remarkable 
degree  proportionate  to  the  liability  to  inflammation  of  the 
navel.    So,  in  tracing  out  the  exciting  cause  of  this  disease, 
it  will  be  of  great  advantage  to  enquire  very  particularly 
into  these  accessory  causes  and  their  morbid  influences  on 
that  part.     By  a  proper  examination  and  consideration  of 
these  advenient  causes — nearly  always  occurring  in  the 
cases  of  negro  infants — we  may  be  able  to  answer  the  ap- 
propriate and  important  question,  Why  are  the  infants  of 
our  slaves  more  liable  to  tetanus  than  those  of  the  whites  ? 
This  is  indeed  a  strong  question  and  much  in  point ;  which 
when  truthfully  solved,  its  answer  cannot  be  much  short  of 
a  solution  of  the  main  problem.     No  one  I  presume  will 
assume  that  the  children  of  our  negroes  are  more  obnoxious 
to  tetanus  from  a  connate  diathesis  peculiar  to  the  African 
race,  than  are  the  whites.     An  assumption  of  this  kind 
may  be  refuted  by  stating  the  fact,  that  when  the  children 
of  white  parents,  for  instance,  paupers,  inmates  of  hospitals, 
&c,  are  subjected  to  the  accidental  causes  which  I  shall 
presently  relate,  they,  like  the  children  of  the  blacks,  are 
equally  liable  to  trismus ;  and  moreover,  when  the  latter 
are  exempted  from  such  things,  they  are  no  more  obnoxious 
to  the  disease  than  the  former.     These  facts  are  of  too 
much  importance  to  rest  on  mere  assertion ;  they  must, 
hence,  be  sustained,  for  th^y  contribute  no  liftle  to  the 
elucidation  of  our  subject. 

I  will  now  relate  what  must  accord  with  the  observations 


21 

of  most  physicians  who  have  done  much  practice  among 
negroes.  When  called  to  see  their  children  we  find  their 
clothes  wet  around  their  hips,  and  often  up  to  their  arm 
pits,  with  urine ;  smoking,  fretting  and  kicking,  the  child 
is  thus  presented  to  us ;  when,  on  examination,  we  find  the 
umbilical  dressings  not  only  wet  with  urine,  but  soiled 
likewise  with  feces,  freely  giving  off  an  offensive  urinous 
and  fecal  odor,  combined  at  times  with  a  gangrenous  fetor, 
arising  from  the  decomposition— not  desiccation — of  the 
cord.  May  I  not  say,  that  a  vital,  physiological  drying 
and  separation  of  the  funis  under  such  circumstances  is 
impossible ;  hence  the  frequency  of  a  pathological  condition 
of  the  umbilicus  in  such  cases,  and  I  will  add,  the  frequent 
occurrence  of  lock-jaw  also  among  them.  Moreover,  these 
navel  dressings  are  not  only  thus  acted  on  by  the  child's 
urine  and  feces,  but  they  also  become  impregnated  with  a 
filthy,  irritating  moisture,  constantly  exuding  from  the 
sphacelated  cord ;  there  comes  likewise  an  occasional  inter- 
vening dry  rough  state  of  these  foul  deathful  appliances, 
during  which  they  rub,  irritate  and  excoriate  a  surface  al- 
ready excited  by  those  foul  agencies  just  mentioned. 
Nor  is  this  all.  Negro  children  are  often  improperly  fed. 
and  suffer  from  colic,  and  abdominal  distention,  causing 
them  to  fret,  cry  and  kick,  thereby  producing  abdominal 
movements  well  caclulated  to  bring  umbilical  dressings  in 
rough  contact  with  their  navels.  Their  mothers  never  think 
of  changing  these  hurtful  dressings ;  either  from  a  want  of 
changes,  or  a  disinclination  to  do  so,  they  let  them  re- 
main on — bandage  and  all — until  the  funis  sloughs  ;  after 
this  the  applications  are  almost  as  hurtful  as  those  pre- 


22 

viously  employed — such  as  soot.,  dry  dirt  out  of  the  back 
of  the  chimney,  scorched  cotton,  greasy  cloth  folded  up 
into  a  hard  compress,  and  a  bandage  drawn  around  these 
with  unmerciful  tightness.  That  there  are  many  excep- 
tions to  this  deplorable  state  of  things,  I  readily  admit ; 
so  I  might  add,  there  are  many  exceptions  to  attacks  of 
tetanus ;  more  indeed  of  the  latter  than  the  former,  for 
every  child  that  has  a  sore  navel  does  not  consequently 
have  trismus.    But  more  of  this  presently. 

I  have  enquired  very  particularly  of  the  overseers  of 
large  plantations  with  numerous  slaves,  about  the  man- 
agement of  their  negro  children,  and  in  every  instance 
where  the  mistress  attended  carefully  to  the  dressing  of 
the  umbilicus,  very  few  or  no  cases  of  trismus  occurred. 

Mrs.  P 1,  a  very  motherly  intelligent  lady,  informed 

me  that  she  had  raised  about  twenty  little  negroes,  also, 
a  goodly  number  of  her  own  children,  and  that  none  horn 
on  her  place  ever  died  of  tetanus.  She  stated  further 
that  she  always  paid  very  strict  attention  to  their  navels, 
and  in  no  instance  trusted  the  management  of  them  to 
their  mothers.  Now,  it  is  worthy  of  remark,  that  Dr.  Ii. 
has  a  quarter  in  sight  of  the  place  just  mentioned,  on 
which  thirty  or  forty  negroes  constantly  reside.  This  plan- 
tation has  been  for  more  than  twenty  years  under  the 
management  of  overseers ;  one  of  them  had  the  care  of  it 
fifteen  years,  during  which  period  only  two  children  died 
of  lock-jaw;  the  next  overseer  was  retained  four  years, 
daring  which  time  four  children  were  attacked  and  died 
of  this  disease;  the  third  superintendent  remained  two 
years,  in  which  time  two  deaths  occurred  from  infantile 


23 

lock-jaw.  The  wife  of  the  first  overseer  was  an  excellent 
nurse,  and  fully  appreciated  the  danger  of  a  sore  navel. 
She  paid  careful  attention  to  the  navels  of  the  little  ne- 
groes, but  her  appropriate  measures  were  sometimes  de- 
feated by  the  carelessness  of  their  mothers,  during  her 
absence  from  their  houses.  Yet,  out  of  the  great  number 
of  children  born  on  this  place  in  fifteen  years,  only  two 
died  of  sore  navel  or  its  sequence,  trismus.  The  wife  of 
the  next  overseer  was  young,  inexperienced  and  had  no 
turn  for  attending  to  little  negroes,  so  four  died  while  she 
was  there ;  and  the  same  may  be  said  of  the  wife  of  the 
last  mentioned  superintendent,  and  the  same  result  fol- 
lowed. 

In  the  last  fifteen  years,  -Mr.  B h  has  had  fifteen  color- 
ed infants  born  on  his  plantation,  during  which  time,  his 
mother,  who  was  a  midwife,  resided  on  the  same  place,  and 
paid  great  attention  to  the  umbilk.il  dressings,  and  not  a 
single  case  of  lock-jaw  occurred  while  she  lived ;  she  died 
a  few  years  ago,  and  since  her  death  but  one  negro  child 
had  been  born  on  the  place,  and  that  died  of  sore  navel 
and  tetanus. 

Mrs.  H e,  a  very  intelligent  and  domestic  lady  has 

assured  me  that  she  has  raised  upwards  of  twenty  little 
negroes  on  their  plantation,  and  not  one  born  on  their 
place  had  ever  been  attacked  with  trismus — that  she  never 
in  any  case,  trusted  the  navel  of  the  child  to  the  care  of 
its  mother,  but  always  attended  personally  to  its  dressings. 

Mr.  W n,  who  owns  a  number  of  slaves,  told  me,  just 

after  giving  some  directions  about  the  management  of  the 
navel  of  a  child  whose  mother  I  had  just  delivered,  that 


24 

he  had  lost  not  less  than  twelve  or  thirteen  little  negroes 
from  sore  navel.  This  gentleman  had  the  misfortune  to 
lose  his  wife  many  years  ago,  and  the  care  of  the  little 
children  had  been  entrusted  exclusively  to  their  mothers. 
Whence,  I  ask,  is  this  great  difference  of  mortality  in  the 
two  last  examples? 

Many  more  illustrations  of  this  kind  might  be  reported 
but  it  is  scarcely  worth  while  to^ultiply  them.  Any  one 
who  is  anxious  to  obtain  additional  information  on  this 
subject  may  do  so  by  inquiring  of  the  heads  of  other 
families,  and  they  cannot  fail  to  be  impressed  with 
the  fact,  that  when  physicians  or  intelligent  nurses  attend 
to  the  little  negro  children,  cases  of  infantile  lock-jaw  are 
very  rare ;  so  much  so  indeed,  that  a  negative  course  in 
that  respect  towards  them  plainly,  in  its  consequences,  in- 
dicates the  exciting  cause  of  the  disease.  To  conclude  the 
present  naration  of  facts,  T  will  now  introduce  several  com- 
munications on  the  subject,  which  I  have  lately  received. 

The  following  extracts  from  a  communication  which  I 
have  just  received  from  Dr.  P.  D.  McCulloch,  of  this  place, 
on  the  subject  of  Trismus  Nascentium,  will  be  read  with 
interest  by  all  who  are  disposed  to  investigate  the  phenom- 
ena of  this  dreadful  pathos : 

"  I  have  only  investigated  the  cases  which  occurred  in 
two  large  families,  as  they  presented  the  largest  number  of 
deaths  in  proportion  to  the  number  of  births  among  them. 
In  the  first  family,  comprising  sixty  or  seventy  blacks, 
there  have  been  within  the  last  eight  years  twenty  births ; 
five  of  these  died  within  the  tenth  day  of  their  birth,  and 
all  of  them  with  symptoms  of  Trismus,  according  to  a  re- 


25 

liable  history  of  the  cases.  None  of  these  received  any 
attention  from  the  white  family  until  they  had  plain  symp- 
toms of  the  disease.  In  only  one  of  these  cases  was  the 
umbilicus  examined,  in  which  the  phenomena  of  well  marked 
inflammation  were  present.  I  examined  into  the  method 
usually  pursued  by  the  attendant  with  her  navel-dressings, 
and  found  it  had  been  the  custom  of  the  old  negress,  who 
always  attended  to  the  children,  when  the  funis  became 
partially  detached,  to  remove  it  and  dress  the  wound  with 
common  chimney  soot.  After  this  was  ascertained,  the 
lady  of  the  farm  attended  to  the  children  in  a  great  mea- 
sure herself;  since  which  time — three  or  four  years  ago — 
there  has  not  been  a  case  of  the  disease,  although  there 
has  been  a  number  of  births  since  that  period.  It  might 
not  be  amiss  to  add  that  four  or  five  white  children  were 
born  on  this  plantation  during  the  above  period,  and  that 
none  of  them  were  attacked  with  this  disease. 

"  In  the  second  family,  which  contained  about  the  same 
nnmber  of  whites  and  blacks,  twenty  or  twenty-five  chil- 
dren were  born  during  the  same  period  of  time.  Six  of 
these  children  died  of  Trismus.  The  navels  were  examined 
in  all  these  cases,  and  were  found  to  be  in  an  unhealthy 
condition  in  every  instance.  The  dressings  used  on  this 
farm  were  usually  nothing  more  than  a  coarse  domestic 
pad,  placed  over  the  severed  funis,  and  bound  down  by  a 
common  bandage.  The  last  of  these  cases  occurred  about 
four  J  ears  ago ;  from  which  time  to  the  present  the  chil- 
dren born  on  this  place  have  been  strictly  attended  to  by 
some  of  the  white  family,  until  they  had  passed  the  time 


26 

of  an  attack  of  this  disease.     No  case  occurred  at  any 
time  among  the  white  children  on  this  plantation." 

Dr.  M.  Ransom,  late  of  Texas,  but  now  of  our  county, 
who  resided  some  time  on  the  Brasos,  about  thirty  miles 
from  Houston,  has  also  kindly  furnished  me  with  some  in- 
teresting facts,  which  I  will  now  adduce : 

u  According  to  your  request,  I  send  you  a  few  notes  on 
Trismus  Nascentium,  which  I  took  during  the  summer  of 
1849,  while  in  Texas.  My  information  with  regard  to  its 
occurrence  here,  until  1849,  was  obtained  chiefly  from 
intelligent  citizens  very  capable  of  recognizing  the  disease- 
It  was  not  observed  here,  as  far  as  I  can  learn,  until  about 
1845  or  '46,  since  which  time  its  prevalence  has  gradually 
increased  every  summer.  Last  year  the  mortality  was 
very  great  from  it,  amounting  in  one  or  two  instances  to 
four-fifths  of  all  the  children  born  on  some  plantations, 
while  on  many  others  not  one  died.  As  a  general  rule, 
there  has  been  either  a  very  considerable  mortality  on  a 
place,  or  none  at  all.  The  disease  appears  in  about  one- 
half  of  the  families,  and  those  families  lose  about  one-half 
of  their  infants  on  an  average.  The  number  of  deaths 
from  this  disease  among  white  children  is  comparatively 
small.  This  malady  is  much  more  frequent  in  negro  quar- 
ters than  in  families  where  the  children  are  more  directly 
under  the  supervision  of  white  persons.  It  also  prevails 
more  extensively  in  the  river  bottoms,  where  the  planta- 
tions are  surrounded  by  dense  forests,  hung  with  moss, 
than  in  the  prairies  where  the  Gulf  breezes  are  unobstruct- 
ed.    It  occurs,  I  may  add,  much  more  frequently  in  filthy, 


27 

ill-ventilated  houses,  than  in  clean,  well  aired  ones,  and  is 
far  more  prevalent  in  summer  than  in  winter. 

"  I  have  never  seen  a  case  of  Trismus  where  the  umbil- 
icus was  in  a  healthy  condition ;  it,  on  the  contrary,  was 
generally  swollen,  irritable  and  not  suppurating. 

"  I  have  never  known  a  recovery  from  a  well-marked 
case  of  this  disease,  except  perhaps  in  a  single  instance ; 
which,  if  effected  by  any  remedy,  it  was  incisions  over 
the  swollen  umbilicus.  But  this  was  tried  at  other  times 
without  the  least  success. 

"Nothing  had  been  done  by  way  of  preventing  this 
disease  until  this  summer,  except  the  occasional  adminis- 
tration of  small  doses  of  calomel  or  castor  oil  for  a  week 
or  two  after  the  birth  of  the  child.  During  the  present 
summer  many  of  the  plantations  have  employed  the  means 
suggested  by  the  above  facts  for  its  prevention.  The  ne- 
gro houses  were  freely  ventilated,  and  the  bedding  and 
everything  about  their  houses  kept  clean.  The  thick 
greasy  musquito  bar  which  was  before  allowed  to  hang 
around  the  bed,  enclosing  the  woman  and  her  child  in  a 
confined,  impure  atmosphere,  was  stripped  off,  and  the  pure 
air  allowed  to  circulate  freely  around  them.  The  nurse 
was  directed  to  apply  some  stimulating  ointment,  such  as 
red  precipitate,  or  calomel  to  the  navel,  from  the  second 
day  until,  it  was  perfectly  healed.  When  these  prophylac- 
tics were  properly  attended  to,  they  suffered  very  little 
from  the  disease ;  while  on  other  plantations,  where  they 
were  neglected,  it  prevailed  as  extensively  as  it  did  the 
previous  surnm*.     I  have  had  no  opportunity  of  seeing 


28 

one  of  these  preventives  employed  to  the  exclusion  of  the 
others ;  hence,  have  no  evidence  that  one  is  more  efficacious 
than  the  other." 

Dr.  Thomas  C.  Black,  of  our  county,  well  known  as  a 
close  observer  of  the  phenomena  of  disease  has  obligingly 
furnished  me  with  the  following  statements : 

u  In  reply  to  your  inquiry  about  my  opinion  in  the  dis- 
ease usually  called  Trismus  Nascentium,  I  can  state  that 
during  eight  or  ten  years  of  the  early  part  of  my  profes- 
sional life,  I  was  pretty  actively  engaged  in  practice, 
and  I  suppose  treated,  at  least,  my  proportion  of  such 
cases.  I  regret  that  I  must  say  that  I  have  nothing  to 
offer  as  a  remedy  nor  any  treatment  to  propose  which 
promises  much  towards  the  cure  of  the  disease ;  for  I  have 
never  seen  a  well-marked  acute  case  get  well.  A  very 
large  proportion  of  the  cases  which  I  have  met  with,  have 
been  among  negroes.  In  1845  or  '46,  I  lost  three  little 
negroes,  on  my  plantation  in  Mississippi,  with  the  disease. 
The  children  were  at  the  Quarter,  and  under  the  exclusive 
management  of  careless  negroes,  nearly  a  mile  from  the 
dwelling  house. 

I  have  always  been  of  the  opinion  that  the  disease  had 
its  origin  in  the  unhealthy  condition,  or  unnatural  cicatri- 
zation of  the  umbilicus;  and  in  most  of  the  cases  with 
which  I  have  met  I  thought  I  could  trace  the  result  back 
to  bad  management  of  the  cord.  In  one  case  of  the  little 
negroes  which  I  lost,  there  were  evident  signs  of  inflam- 
mation of  the  umbilicus. 

I  have  no  recollection  of  having  noticed  any  symptoms 


29 

which  indicated  cerebral  disease  in  any  case  that  I  have 
treated.  The  cases  which  I  have  seen  occurred  invariably 
from  the  fifth  to  the  tenth  day  after  the  falling  off  of  the 
cord." 

The  following  communications  from  Dr.  J.  W.  Morton, 
give  additional  confirmation  of  these  views : 

"  In   answer  to  your   interrogatories    on  the  subject 
of  Trismus  Nascentium,  I  will  say,  that  I   commenced 
the    practice  of   medicine  in  Williamson    county,  Ten- 
nessee, in  a  section  of  country  very  densely  populated 
with  negroes.     The  farmers  owning  these  negroes,  had 
on    almost   every    one    of    their    farms    a    number   of 
breeding    women,    all  of  whom,    when    confined,    were 
entrusted  to  female  midwives,  of  the  most  ignorant  order 
of  women,  some  of  them  were  the  old  women  belonging 
to   the    plantation.     With    such    services    as  could    be 
rendered    by    these   attendants,    we    could  but    expect 
that    both   mother    and    child    would    frequently  suffer 
from     neglect,    if    not    from    maltreatment,     at    their 
hands.     This  was   by  no  means  unfrequently  the  case. 
Trismus  Nascentium  upon  some  plantations  occurred  so 
frequently  as  to  lead  the  farmers  to  conclude  it  was  pecu- 
liarly and  particularly  confined  to  the  offspring  of  some 
of  their  women,  for  they  would  loose  a  number  of  children 
in  succession,  leading  their  owners  to  suspect  that  the  cause 
of  the  misfortune  depended  upon  some  malicious  or  bad 
conduct  on  the  part  of  the  mother.     Indeed  I  have  known 
masters  who  were  ignorant   of  the  cause  of  this  malady, 
to  become   much    exasperated    with  favorite    servants, 


30 

believing  they  in  some  way  maliciously  caused  the  death 
of  their  children,  and  then  sell  them  to  traders  with  an 
express  injunction  they  should  be  carried  to  the  South. 
This  the  farmers  would  do  as  a  punishment  to  the  unfor- 
tunate mother,  as  well  as  to  make  an  example  of  her  to 
her  fellow-servants,  to  terrify  them  from  a  crime  of  which 
they  thought  them  guilty. 

Having  located  in  such  a  region  of  country,  it  was  my 
province  to  be  very  frequently  called  to  cases  of  Trismus 
Nascentium.  When  I  would  arrive  and  enquire  of  the 
midwife  or  nurse  what  seemed  to  be  the  matter  with  the 
child,  their  almost  universal  reply  was,  the  child  had  the 
bold  hives,  and  they  could  not  get  them  to  break  out 
Upon  examination,  I  would  find  the  child  far  advanced 
into  Trismus  Nascentium.  In  the  early  part  of  my  pro- 
fessional career  I  read  almost  every  authority  of  which  I 
could  get  possession  to  inform  myself  as  to  the  true 
cause  of  this  malady ;  but  in  vain.  The  authors  seem  to 
lead  their  readers  to  no  just  conclusion  whatever  as  to 
what  might  be  its  proper  source.  Sometimes  I  was  ready 
to  conclude  the  disease  depended  upon  some  irritating 
cause  in  the  abdominal  viscera.  Again  I  would  conclude 
it  v  depended  upon  irritation  of  the  spinal  column,  con- 
nected with  irritation  of  the  great  sympathetic  plexus  of 
nerves.  At  other  times  upon  some  organic  disease  dis- 
turbing the  brain  or  its  enveloping  membranes.  Some- 
times I  looked  to  the  umbilicus  as  being  the  source  of  the 
evil. 

With  all  these  conclusions  before  me,  I  was  frequently 
left  in  very  great  doubt  as  to  which  of  these  causes  I 


31 

should  attribute  the  attack,  and  sometimes,  I  must  admit, 
I  was  at  very  great  loss  to  know  whether  or  not  I  should 
lay  the  cause  at  the  door  of  any  one  of  them,  or  to 
all  of  them  combined.  But  about  fourteen  or  fifteen 
years  ago,  the  precise  time  I  do  not  now  recollect,  not 
having  the  Journal  before  me,  in  looking  over  the  original 
communications  published  in  the  American  Journal  of  the 
Medical  Sciences,  I  saw  and  read  the  essay  of  Dr.  Sims, 
then  of  Alabama,  but  now  of  the  city  of  New  York,  with 
a  great  deal  of  anxiety  as  well  as  interest,  upon  the  sub- 
ject of  Trismus  Nascentium.  After  perusing  his  essay,  I 
thought  he  had  discovered  the  cause  as  well  as  the  treat- 
ment which  would  never  fail  to  relieve  it,  Hence,  I  made 
known  the  discovery  of  Dr.  Sims  to  my  friends  and 
patrons,  assuring  them  I  believed  by  his  indefatigable  in- 
dustry and  observation  he  had  given  to  the  profession  a 
key  that  would  never  fail  to  unlock  the  jaws  of  all  tris- 
matic  infants. 

Very  soon  I  was  called  to  a  case.  I  examined  carefully 
the  child's  head,  expecting  to  find  without  the  least  trouble 
the  displacement  of  the  occiput,  so  graphically  described 
by  Dr.  Sims;  but,  to  my  utter  astonishment,  the  bones 
seemed  to  be  in  their  proper  position ;  yet  having  so  much* 
confidence  in  his  theory  as  well  as  practice,  I  adopted  his 
treatment  of  lateral  position  of  the  child,  for  several  hours, 
at  the  same  time  using  such  other  means  as  the  case 
seemed  to  indicate,  without  the  least  beneficial  effect  what- 
ever. The  result  of.  this  case  did  not,  by  any  means,  de- 
stroy my  confidence  in  the  theory  or  practice  proposed  by 
Dr.  Sims;   for  I  continued  to  try  the  lateral  position 


32 

every  ease  I  saw  before  getting  one  in  whidh  I  im- 
agined the  occiput  had  been  pressed  forward  beneath  the 
edges  of  the  parietal  bones,  all  of  which  terminated  in  death, 
as  the  first  had  done.  At  last,  I  was  called  to  a  case,  the 
child  of  a  mother  who  had  lost  her  two  children  born  pre- 
viously to  tins  one.  This  mother  expressed  great  solici- 
tude for  the  relief  of  her  child,  and  upon  my  examining  the 
child's  head,  and  finding,  as  1  thought,  the  displacement 
of  the  occiput,  I  immediately  communicated  to  her,  as  1 
fancied,  the  cause  of  the  distress  of  her  child,  and  the 
opinion  that  I  would  be  able  to  relieve  it.  I  determined  I 
would  adopt  Dr.  Sims's  treatment,  first  by  dislodging  the 
misplaced  bone  from  beneath  the  parietal  bones,  secondly 
by  enforcing  strictly  the  lateral  position  prescribed  by 
him.  Having  no  instrument  better  suited  to  the 
operation,  I  used  a  common  shoemakers's  awl,  pressing 
the  point  of  the  instrument  sufficiently  deep  into  the 
external  table  of  the  occiput  to  prevent  its  breaking  outs, 
when  I  made  very  firm  pressure  backwards,  until  I  con- 
ceived I  had  completely  restored  the  bone  to  its  natural 
position;  to  my  astonishment,  when  I  removed  the  awl, 
the  bone  resumed  the  position  in  which  I  found  it.  I 
made  this  experiment  several  times  upon  one  side  at  a 
time,  and  then  upon  both  sides  simultaneously,  with  the 
same  result.  This  child  died  in  a  short  time  after  I  ceased 
my  experimental  operations.  Soon  after  this,  I  was  called 
to  a  second  case  in  which  I  imagined  the  occiput  was 
pressed  forward  beneath  the  parietal  bones ;  upon  this  I 
operated  also,  with  the  same  result  as  the  other. 


33 

I  now  came  to  the  conclusion,  that  either  Dr.  Sims 
was  mistaken  both  in  his  theory  and  practice  in 
Trismus  Nascentium,  or  that  I  was  wanting  in  dexterity 
to  adopt  his  lateral  position  properly,  or  perform  his 
operation  with  success.  The  result  of  these  experi- 
ments left  me  in  the  same  doubtful  and  unsettled  opinion 
about  the  cause  and  cure  of  this  malady.  In  fact, 
I  very  soon  came  to  the  conclusion,  that  there  was 
no  successful  mode  of  treating  it,  and  frequently  when 
sent  for  to  see  a  child  laboring  under  the  disease, 
I  refused  to  visit  it,  acknowledging  to  those  inter- 
ested I  could  do  nothing  that  promised  any  relief 
whatever,  not  even  as  a  paliative.  For  some  years  I  gave 
up  all  such  cases  to  their  fate,  and  even  now,  I  have 
no  curative  remedy  to  suggest,  and  when  requested  to 
visit  a  child  with  Trismus,  I  frankly  tell  the  mes- 
senger that  I  can  do  as  much  for  the  relief  of  the 
little  sufferer  as  any  other  physician  probably  could, 
yet  acknowledge  I  can  do  nothing  that  would 
be  of  any  material  service.  My  experience  is,  that 
all  such  patients  die  as  certainly  as  adults  die  of 
traumatic  tetanus,  of  which  disease  a  physician  may 
probably  see  one  case  of  recovery  in  the  course  of  a 
long  professional  life. 

We  must  not  think  of  curing  the  disease,  but  as  you 

have  very  justly  taught  in  your  essay  published  some 

eight  or  ten  years  ago  on  the  subject  of  Trismus  Nas- 

centium,  the   safety  of  the   child  will    depend  -on   the 

adoption  of  such  hygiene  measures  as  will  prevent  it. 

Your  theory  of  the  cause  of  this  disease,  and  the  ardent 
3 


34 

manner  in  which  yon  have  impressed  it  upon  the 
students  of  the  medical  classes,  to  whom  you  have  had 
the  pleasure  of  lecturing  since  your  connection  with  the 
'•University  of  Nashville  as  well  as  upon  the  profession 
,  generally,  through  your  essay,  has  saved  the  lives  of  more 
children,  which  might  have  died  of  Trismus,  since  its  publi- 
cation, than  all  the  remedies  that  have  been  employed  for 
its  cure  since  the  days  of  Hippocrates. 

The  condition  of  the  umbilicus,  it  is  true,  is  only  an 
exciting  cause  of  Trismus  Nascentium,  just  as  the  prick- 
ing the  sole  of  the  foot  of  an  adult  with  a  nail  is  the 
cause  of  traumatic  tetanus.  There  are  various  other 
causes  acting  upon  the  economy  in  either  disease  tend- 
ing to  bring  about  a  tetanic  diathesis  of  the  system,  which 
only  requires  a  very  small  exciting  cause  to  develope 
the  disease.  There  is  scarcely  a  man  in  this  com- 
munity who  has  not  seen  Tetanus  in  the  adult  pro- 
duced by  pricking  the  sole  of  the  foot  with  some  sharp 
pointed  instrument.  Morgagni  tells  of  a  young  lady 
who  was  attacked  with  the  disease  in  consequence  of  a 
bite  from  a  tame  sparrow.  Dr.  Reid  relates  a  case  which 
occurred  from  the  stroke  under  the  eye  with  the  lash  of 
a  whip,  which  was  so  light  as  not  to  destroy  the  continuity 
of  the  skin.  Andral  relates  a  case  that  was  the  conse- 
quence of  a  seton  being  inserted  into  the  breast  of  a 
patient.  The  extraction  of  a  tooth  has  been  followed  by 
tetanus.  I  have  myself  seen  tetanus  follow  wounds  so 
slight  as  not  to  excite  the  least  attention  whatever  until 
the  patient  was  completely  overwhelmed  with  tetanic 
spasms.    When  we  see  this  disease  so  frequently  follow 


35 

wounds  of  so  slight  a  character  in  the  adult,  how  can  we 
reasonably  doubt  that  the  cause  of  Trismus  Nascentium 
is  the  irritation,  inflammation,  suppuration  or  ulcera- 
tion of  the  umbilicus.  I  am  conscious  of  one  fact,  that 
since  my  attention  has  been  directed  to  proper  dressing 
and  care  of  the  umbilicus  in  the  children  of  my 
practice,  the  mortality  from  Trismus  has  been  reduced  to 
at  least  one  hundred  per  cent.,  even  when  the  care  of 
them  has  been  entrusted  to  nurses." 

Dr*  McCulloeh's  cases  are  in  full  agreement  with  the 
general  history  of  Trismus  Nascentium..  The  truths  ad- 
duced by  him  accord  not  only  with  my  own  observations, 
but  with  those  of  others. 

Dr.  Hansom's  notes,  taken  while  he  was  in  Texas,  show 
the  great  activity  of  predisposing  causes;  also,  how  gener- 
ally and  easily  children  are  affected  by  a  morbid  state  of 
the  navel,  when  they  come  under  the  influence  of  such 
predisponents.  Dr.  Clarke's  hospital  cases  illustrate  the 
same  truths.  After  all,  it  is  not  very  surprising  that 
such  predisposing  causes  should  have  been  mistaken  by 
Dr.  Clark,  and  others,  for  the  exciting  cause.  So  little 
attention  has  been  paid  to  the  proper  relation  of  causes  by 
writers  on  this  disease,  that  it  seems  very  few  have 
attached  sufficient  importance  to  remote  influences,  or  to 
a  particular  diathesis  of  the  system,  but  have  been  con- 
tent to  examine  alone  into  the  exciting  cause ;  and  this, 
consequently,  when  very  weak  or  obscure,  has  not  received 
that  consideration  which  it  even  then  deserves,  in  its  rela- 
tion to  a  predisposition  to  tetanus.     Hence  the  great 


36 

necessity  of  regarding  these  causes  according  to  their 
mutual  dependence  on  each  other,  that  we  may  see  their 
joint  agencies,  in  producing  an  attack  -of  this  disease ; 
also,  that  they  may  reflect  a  reciprocal  light  on  the 
obscure  plastic  forces  of  the  invading  pathos.  The  gene- 
ral history  of  traumatic  tetanus  teaches  us  that  it  is  more 
easily  excited  in  adults  by  wounds  sometimes  than  at 
others,  according  to  the  prevalence  and  activity  of  predis- 
posing causes.  This  all  admit.  Whence  then  the  neces- 
sity or  propriety  of  entertaining  or  propagating  different 
opinions  as  to  these  causes,  and  their  effects  in  cases  of 
infantile  tetanus,-  associated  as  it  often  is  with  palpable 
irritation  and  inflammation  of  the  umbilicus? 

Just  here,  I  must  reply  to  two  very  specious  objections 
to  a  proper  view  of  this  subject. 

1.  That  the  navel  may  be  badly  inflamed,  and  yet  not 
cause  tetanus.  -       .  • 

2.  That  cases  of  Trismus  have  occurred  wjien  there 
was  no  inflammation  of  the  umbilicus. 

But  for  these  considerations  many  would  doubtless  have 
entertained  a  much  greater  dread  of  a  morbid  state  of  the 
umbilicus,  and  would  oftener  have  employed  tetano-pro- 
phylactic  measures  in  such  cases.  Indeed,  with  no  little 
astonishment  have  I  heard  well  informed  physicians  say, 
they  did  not  believe  that  inflammation  of  the  navel  is  the 
exciting  cause  of  Trismus,  merely  because  they  had  seen 
very  badly  inflamed  ones,  without  the  occurrence  of  lock- 
jaw; or,  that  they  had  seen  cases  where  the  umbilicus 
had  healed  over.  Verily  my  surprise  would  be  only 
equaled  by  the  assertion,  that  they  did  not  believe  that  a 


37 

wound  was  the  exciting  cause  of  tetanus  in  the  adult, 
because  they  had  seen  very  bad  ones  fail  to  produce  it,  or 
had  seen  cases  occur  after  the  healing  over  of  wounds. 
Almost  every  practitioner  knows,  from  personal  obser- 
vation that  an  adult  may  receive  a  deep,  dangerous,  and 
painful  wound  without  incurring  lock-jaw  as  a  conse- 
quence ;  also,  that,  a  wound  may  cause  the  disease  after 
having  healed  over.  Then,  may  not  severe  inflamma- 
tion, or  extensive  ulceration  of  a  child's  navel  run  its 
course  without  causing  trismus?  and  may  not  the  part 
heal  over  and  yet,  by  an  occult  pathological  condition, 
excite  the  disease? 

When  we  are  called  to  see  an  adult  patient  laboring 
under  this  malady,  and  learn  that  he  has  been  suffering 
from  a  wound,  however  great  or  small,  whether  from  a 
cannon  ball  or  prick  of  a  needle,  we  give  ourselves  no 
further  concern  about  finding  out  the  exciting  cause; 
or,  if  we  visit  one  in  whom  a  recent  wound  has  healed 
over,  and  who  notwithstanding  is  suffering  from  an  attack 
of  this  disease,  we  feel  confident  that  the  cicatrix  is  in  a 
morbid  state  and  has  excited  the  disease.  But  when  some 
practitioners  are  called  to  see  an  infant  afflicted  with  teta- 
nus, they  may  learn  that  the  child's  navel  is  even  badly 
inflamed,  swollen  and  irritable,  and  yet  ascribe  the  child's 
attack  to  some  other  exciting  cause !  Or,  an  infant  may 
be  seen  with  the  disease,  when  the  umbilicus  has  healed 
over,  and  instead  of  referring  the  attack  to  an  unhealthy 
irritable  condition  of  the  navel,  though  healed,  as  they 
do  in  cases  of  adults,  this  occult  pathological  state  of  the 
part  is  overlooked  by  them,  and  the  disease  is  said  to 


38 

have  been  brought  on  by  some  other  exciting  cause ! 
And  yet,  forsooth,  had  the  little  patient  been  an  adult, 
with  a  badly  inflamed,  swollen,  and  painful  umbilicus,  or 
.  with  one  that  had  just  healed  over,  after  having  been  in  a 
morbid  condition,  the  exciting  cause  would  have  been 
readily  enough  admitted.  Hence,  if  I  have  not  gained 
the  point  which  I  had  in  view,  the  Redudio  ad  absurdum, 
I  have,  at  least,  that  of  the  Redudio  ad  discrepantiam. 
A  strange  inconsistency  has  indeed  been  presented.  It  is 
even  preposterous,  I  must  insist  for  any  one  to  admit, 
that  a  slight  wound,  either  before  or  after  it  has  healed 
over,  may  produce  tetanus  in  adults,  and  then  deny  that 
inflammation  and  ulceration  of  the  navel  do  not  excite  it 
in  infants,  neither  before  nor  after  the  part  has  healed. 

Really,  when  we  reflect  on  the  great  constitutional  deli- 
cacy of  infants,  their  great  proneness  to  cerebral,  spinal, 
and  nervous  disorders,  as  well  as  their  general  suscepti- 
bility of  disease,  we  would  err  less  in  supposing  that  their 
frequent  sore  navels  were  more  likely  to  cause  tetanus  ia 
them,  than  common  wounds  in  adults.  Assuredly,  both 
adults  and  infants  are  liable  to  attacks  of  tetanus  after 
wounds  or  ulcers  have  healed  over ;  all  admit  that  the 
former  are,  and  that  the  latter  are  equally  so  cannot  be 
either  truthfully  or  consistently  denied.  A  tetano-patho- 
logical  condition  of  such  cicatrices  cannot  be  detected  by 
any  known  means  anterior  to  an  open  attack,  especially 
in  the  cases  of  children,  as  they  cannot  complain  of  any 
irritation  or  pain  which  may  be  produced.  And  yet,  we 
very  often  hear  those  of  "  fixed  ideas"  about  their  imagi- 
nary causes  of  this  malady  say,  that  in  their  cases  the 


39 

navel  was  healed  over  and  looked  very  well,  consequently 
the  disease  must  have  been  excited  by  some  other  cause 
than  by  a  morbid  state  of  that  part.  The  fallacy  of  such 
a  conclusion  has  been,  I  hope,  fully  exposed ;  in  further 
proof  of  which,  however,  many  cases  might  be  adduced, 
but  I  will  only  cite  two,  both  of  very  recent  occurrence : 
A  few  days  ago  I  was  called  to  see  a  negro  boy  ten  or 
twelve  years  old  suffering  from  a  plain,  fatal  attack 
of  tetanus,  brought  on  by  a  small  wound  which  had 
lately  healed  over  and  had  been  lost  sight  of  until 
that  time.  I  saw  a  similar  case  afterwards,  with  several 
physicians,  equally  as  well  marked  and  fatal  in  its  termi- 
nation. 

I  shall  presently  treat  of  its  symptoms  or  varieties. 
My  chief  aim  now  is  to  recommend  a  reliable  prophylaxis, 
by  which,  a' disease  that  cannot  be  cured,  may  be  prevented. 
Just  here,  it  might  not  be  amiss  to  state,  that  occasionally 
a  patient  gets  well  of  this  malady;  such  a  recovery  is, 
however,  only  an  exception  to  a  general  rule,  which  the 
attending  physician  sometimes  mistaking  for  the  general 
rule  itself,  has  thereby  been  encouraged  to  treat  a  succeed- 
ing case  with  the  same  remedies  which  were  supposed  to 
have  cured  the  case  before,  when  to  his  surprise  and  mor- 
tification he  found  them  of  no  avail.  Many  well-informed 
practitioners  have  lost  all  confidence  in  the  common 
routine  treatment  of  the  day ;  they  entertain  no  reasona- 
ble expectation  of  relief,  only  as  hope  may  be  predicated 
on  the  recovery  of  a  few  exceptionable  cases,  independent 
of  therapeutic  agents.  Hence,  the  great  need  of  some 
prophylaxis. 


40 

The  mother  from  whose  fond  embrace  the  infant  has 
been  suddenly  removed  by  this  unrelenting  foe,  at  a  time 
when  she  needed  all  the  joy  and  comfort  which  her  child 
could  inspire,  may  well,  ask,  what  is  that,  prophylaxis? 
So  may  the  benevolent  physician,  who  has  been  so  often 
foiled  and  mortified  in  his  best  efforts  to  cure  the  malady ; 
even  our  farmers  may  well  ask  the  question  also  in  behalf 
of  their  slave  interest. 

I  will  now  state  by  wray  of  introduction  to  the  prophy- 
laxis which  I  shall,  with  great  confidence,  recommend,  that 
I  have  seen  probably  as  much  obstetric  practice,  both 
among  whites  and  blacks,  as  any  practitioner  out  of  the 
large  cities,  and  never  has  an  infant  been  attacked  with 
tetanus  to  my  knowledge,  of  whose  umbilicus  I  had  the 
management. 

Prophylaxis. — Means  derive  far  greater  consequence 
from  their  salutary  effects  in  particular  instances,  than  we 
could  otherwise  attach  to  them.  While  we  almost  despise 
the  enema  commune,  yet  we  glory  in  its  effects,  when  by 
it,  a  dangerous  and  alarming  obstruction  of  the  bowels  has 
been  relieved.  How  lightly  do  we  also  regard  the  mere 
titillation  of  the  throat  with  a  feather  until  by  its  employ- 
ment we  cause  the  stomach  to  expel  from  its  depths  a 
poison  which  in  a  few  minutes  would  have  destroyed  the 
patient.  Then  we  respect  the  means  and  rejoice  in  the 
effects.  The  lancet  cut  is  but  a  small  thing  in  itself,  and 
yet  we  exult  greatly  in  its  triumphs  over  some  of  our 
most  acute  diseases.  Then  it  is  to  the  effects  of  the  pro- 
phylactic measures,  that  I  will  direct  the  attention  of  the 
reader  as  well  as  the  means  themselves. 


41 

Physicians  have  generally  given  up  the  dressing  and 
management  of  the  funis  too  much  into  the  hands  of 
unskilful  nurses,  lest  by  a  careful  attention  to  such  small 
things,  they  might  compromise  their  fancied  dignity. 
But  every  one  who  is  properly  impressed  with  a  dread  of 
tetanus  from  bad  management  of  this  part,  will  rather  try 
to  maintain  his  professional  character  and  dignity  by  pre- 
venting a  disease  which  he  knows  he  cannot  cure,  however 
trifling  the  means  may  seem  in  the  estimation  of  the 
ignorant,  inexperienced  or  prejudiced. 

The  umbilical  cord  should  be  divided  as  usual  about 
two  inches  from  the  abdomen,  and  well  tied  with  a  suita- 
ble ligature  before  its  division.  After  the  child  has  been 
washed  by  the  ■  nurse,  another  ligature  should  be  applied 
lest  the  first  one  should  become  too  slack  from  the  con- 
traction of  the  cord.  A  hole  of  a  proper  size  should  then 
be  made  through  a  piece  of  soft  old  domestic  or  linen, 
four  inches  wide  and  six  long,  through  which  the  funis 
should  be  passed,  and  afterwards  carefully  wrapped  with 
another  soft  piece  of  cloth,  two  inches  wide  and  three  or 
four  long.  The  cord  should  then  be  turned  up  towards 
the  child's  breast,  and  the  cloth  which  was  first  applied 
should  then  be  folded  in  on  it  from  above  and  below,  and 
from  side  to  side.  A  soft  flannel  bandage  should  then 
be  carefully  put  around  the  addomen  and  pinned  with 
moderate  tightness.  After  this  should  the  navel-dressings 
become  wet  with  urine  or  soiled  with  feces,  they  should  be 
carefully  removed  and  dry  ones  employed.  This  should 
always  be  done  by  an  experienced  and  careful  nurse,  lest 
the  cord  be  prematurely  detached. 


42 

The  chief  advantage  of  wrapping  the  cord,  is  that  of 
preventing  it  from  adhering  to  the  cloth  through  which  it 
passes,  and  thereby  preventing  its  removal  when  necessa- 
ry. All  awkward,  rough  handling  of  the  cord  should  be 
avoided  as  the  navel  string  may  be,  in  that  way,  stretched, 
torn,  or  prematurely  detached.  Our  preventives  begin 
in  little  things ;  too  little,  I  fear,  to  insure  the  regard 
which  they  merit;  were  they  greater  in  professional  esti- 
mation, they  would  be  more  commonly  employed.  As 
the  danger  of  an  attack  of  Trismus  usually  passes  away 
about  the  tenth  or  twelfth  day  of  infantile  life — cases 
rarely  occurring  after  that  time — it  will  be  the  duty  of 
the  conscientious  physician — no  other  will — to  watch  the 
umbilicus  carefully  and  cautiously  up  to  that  period. 
This  duty  is  not  a  difficult  one,  but  may  be  performed 
with  but  little  inconvenience  on  the  part  of  the  practi- 
tioner. But  unfortunately  this  duty  involves  some  little 
particulars,  to  which  he  can  scarcely  stoop.  But  he  must 
stoop,  if  not  "to  conquer,"  to  prevent,  knowing  that  if  he 
does  not  prevent,  he  cannot  conquer. 

The  prevention  of  an  incurable  disease,  let  it  require 
whatever  minor  duties  it  may,  should  dignify  and  exalt 
them  in  professional  estimation,  and  make  it  honorable  to 
employ  them.  The  umbilical  cord,  even  during  delivery, 
should  be  carefully  managed  in  reference  to  this  disease. 
It  should  be  protected  against  too  great  an  extension  at 
the  time  of  birth  :  by  unwrapping  it  from  around  the 
child's  neck,  should  it  be  around  that  part ;  by  not  re- 
moving the  child  too  far  from  the  mother  before  it  is 
divided.     Any  violent  extension  of  the  funis,  in  any  way, 


43 

may  pre-dispose  it  to  separate  by  suppuration,  ulceration, 
or  sloughing.  Besides,  it  might  interfere  with  a  healthful 
contraction  of  the  ventral  opening,  and  that  of  the  vessels 
passing  out  through  it.  A  proper  contraction  of  these 
parts  after  birth  is  a  part  of  the  wonderful  physiology 
performed  by  them ;  for  without,  it,  the  cord  cannot  sepa- 
rate in  a  healthy  manner,  the  abdominal  opening  cannot 
be  closed  nor  the  vessels  which  pass  out  through  it. 
Hemorrhage,  hernia,  and  other  evils  may  ensue  as  con- 
sequences thereof. 

The  parts  which  should  contract  after  birth  are:  1. 
The  foramen  ovale.  2.  The  ductus  arteriosus.  3.  The 
ductus  venosus.  4.  The  umbilical  arteries  and  vein.  5. 
The  ventral '  opening.  Should  not  a  physiological  con- 
traction of  these  foetal  parts — now  superceded  by  a  change 
of  the  circulation  of  the  "blood  in  extra  uterine  life— occur, 
the  separation  of  the  cord  may  be  attended  with  danger: 
If  the  foramen  ovale  should  remain  too  open,  asphyxia 
and  death  may  occur;  or  if  only  partially  so,  carbon 
may,  for  the  want  of  free  pulmonary  circulation,  accumu- 
late in  the  child's  system,  and  produce  debility  and  con- 
vulsions. And  as  the  general  health  thus  impaired,  and 
the  local  congestion  of  the  umbilical  parts  from  partial 
returns  of  the  foetal  circulation,  will  not  admit  of  a  healthy 
desiccation  and  separation  of  the  funis,  Trismus  as  a  con- 
sequence may  follow. 

If  the  umbilical  arteries  were  not  to  contract,  the  dis- 
turbances just  mentioned  might  fill  them  with  blood,  and 
hemorrhage  at  the  navel  would  then  take  place  in  all 
probability ;  and  if  restrained  their  turgid  condition  would 


44 

not  admit  of  a  proper  contraction  of  the  umbilical  opening, 
nor  of  a  safe  disengagement  of  the  cord.  Were  the 
umbilical  vein  to  remain  patulous,  the  blood  might  regur- 
gitate through  it,  and  bleed,  if  not  prevented,  at  •  the 
navel,  especially  if  there  were  any  obstruction  of  the  as- 
cending cava  near  the  heart.  Were  the  ductus  arteriosus 
to  remain  pervious,  too  much  blood  might  pass  out  of  ,the 
way  of  the  pulmonary  circulation. ;  and  in  that  way  con- 
tribute its  moiety  of  distress.  An  open  state  of  the  navel 
itself  will,  of  course,  greatly  predispose  to  hernia,  a  gene- 
ral derangement  of  its  anatomical  parts,  congestion  of 
the  vessels,  hemorrhage,  and  sloughing  of  the  cord. 

It  may  be  said  that  there  is  nothing  in  all  this  likely 
to  predispose  -to  Trismus  by  those  who  are  not  aware 
of  the  danger  of  a  sore,  navel.  Hence,  every  thing 
calculated  in  the  least  to  hinder  the  funis  from  coming 
away  in  a  healthful  manner  may  predispose  to  a  dis- 
eased action  of  the  umbilical  parts.  And  as  this  part 
of  my  subject  relates  so  directly  to  the  anatomy  of  the 
umbilicus,  I  will  give  a  short  description  of  these  parts, 
which  are  so  strikingly  illustrated  in  the  annexed  plate, 
the  representation  of  a  dissection,  made  at  my  request, 
by  my  accomplished  and  talented  young  friend,  Thomas 
B.  Buchanan,  M.  D. 

The  ,anatomy  of  the  umbilicus  consists  of  almost  every 
kind  of  tissue :  Dermoid,  superficial  and  deep-seated 
fascia  and  aponeurosis,  muscular  fibre,  tendon,  nerves 
and  cord,  with  its  vessels,  covering  and  gelatine.  As 
the  abdominal  muscles  are  well  supplied  with  nerves 
from  "the   lower    intercostal,  ilio-hypogastrrc,  and   ilio- 


45 

inguinal  nerves,"  the  umbilicus  of  course  participates  in 
the  endowment. 

'  The  integument,  after  the  detachment  of  the  cord  be- 
comes wrinkled  and  is  folded  in,  and  presents  in  front  a 
cicatrix— a  cicatrix  from  a  physiological  wound  ! — in  the 
strictest  sense  of  the  term.  This  cicatrix  extends,  of 
couise,  through  the  entire  ring — a  cicatrix  of  several  tis- 
sues, as  we  have  just  seen.  Hence,  we  may  expect  often 
to  find  it  in  a  diseased  condition,  which  may  give  rise  to 
tetanus,  as  well  as  an  open  ulcer.*  Just  under  this  integu- 
ment is  the  superficial  fascia  and  aponeurosis,  so  finely 
displayed  in  Dr.  Buchanan's  dissection,  as  seen  in  the 
plate.  Next  may  be  seen  the  aponeurosis  of  the  internal 
oblique  and  transversalis.  Hence,  the  umbilical  ring  is 
formed  in  part  by  the  marginal  contribution  of  the  linea 
alba,  which  is  itself  formed  by  the  "  blending  of  the  ante- 
rior aponeurosis  of  the  oblique  and  transversales  nluscles." 
The  transversalis  fascia  is  also  finely  displayed.  The 
umbilical  cord  with  its  vessels  are  represented  very  promi- 
nently; the  two  arteries  may  be  seen,  as  they  emerge 
from  the  navel,  entwined  around  the  vein. 

*Thc  writer  once  attended  a  well  marked  case  of  traumatic  tetanus, 
caused,  doubtless,  by  a  physiological  lesion  in  another  part.  The  uterine 
surface  from  which  the  placenta  had  been  detached,  like  any  common 
wound,  passed  into  amorbid  condition,  and  produced  the  disease  about  a 
week  after  delivery. 

Dr.  B.  W.  A  vent,  a  very  intelligent  and  well  known'  Physician  and 
Surgeon,  -also,  saw  this  case  and  concurred  fully  in  the  views  just  stated, 
both  as  to  the  cause  and  diagnosis.  .The  prognosis  was  of  course  unfavor- 
able, and  was  verified  in  a,  few  days. 

The  physiology  of  procreation  produces  more  lesions  than  any  other 
variety  thereof,  so  closely  resembling  ordinary  wounds,  that  we  would  re- 
gard them  as  such  were  they  to  occur  in  ordinary  ways.  Thus  we  have 
periodical  hemorage,,  lesions  of  the  Graafian  vesicles,  severance  of  the  pla- 
centa from  the  internal  surface  cf  the*  uterus,  and  on  the  part  of  the  infant 
a  separation  of  the  cord  from  its  abdomen.  Two  of  these  lesions  may 
take  on  a  morbid  state  and  then  cause. a  traumatic  tetanus. 


46 


1.  The  integument  everted. 

.  2.  2.  2.  Superficial  fascia  and  aponeurosis  of  external 
oblique.  * 

3.  Recti  muscles. 

4.  4.  Aponeurosis  of  internal  oblique  and  transversalis. 

5.  Transversalis  fascia. 

7.  Umbilical  cord  dissected. 

8.  Vein. 

9.  9.  Arteries. 


* 


•^  **  -**-"'  ^Mi^r# 


.*•**«•-«•«»#.» 


49 

Thus  we  see  that  the  umbilicus  is  formed  of  a  variety 
of  tissue,  through  which  a  physiological  lesion  must  of 
course  exist,  and  which  must  be  closed  by  a  cicatrix  of 
the  same  kind,  resembling  traumatic  lesion  and  healing 
so  closely  that  we  might  almost  predicate  tetanus  on  its 
physiology,  independent  of  its  pathological  changes.  At 
least  no  one  can  deny  the  necessity  of  guarding  this  teta- 
nic point,  for,  eight  or  ten  days  after  birth.  A  diseased, 
irritable  state  of,  these  parts  is  well  calculated  to  give  rise 
to  tetanus,  abounding  as  they  do  in  nerves,  fascia,  aponeu- 
rosis, both  superficial  and  deep-seated,  dermoid,  and  mus- 
cular structures.  They  constitute  a  week  point  at  the 
ventral  opening,  to  say  the  least,  where  a  natural  state 
may  pass  more  readily  into  an  unhealthy  one,  than  in  any 
other  part  of  the  child's  economy.  Even  a  failure  in 
their  natural  contractions  as  we  have  seen  may  produce 
many  pathological  results. 

The  best  remedy  for  this  state  of  things  is  Ashwell's 
alum  bath.  About  one-fourth  of  a  pound  of  pulverized 
alum  should  be  dissolved  in  a  vessel  of  tepid  water,  large 
enough  for  immersing  the  child  up  to  the  neck,  where  it 
should  be  held  and  carefully  supported  for  ten  or  fifteen 
minutes,  two  or  three  times  a  day,  according  to  the  nature 
of  the  case.  A  little  spirit  of  camphor,  some  pure  brandy 
or  aqua  ammonia  may  be  added  if  the  child  be  very  feeble. 
This  bath  is  clearly  indicated  when  symptoms  of  asphyxia, 
attended  with  blue  lips,  livid  countenance,  defective  respira- 
tion, and  feeble  pulse  occur  in  early  infancy,  denoting  a 
partial  recurrence  of  the  foetal  circulation.  And  as  all 
this  may  be  referred  to  an  open  state  of  the  parts  just 


50 

mentioned,  it  will  be  highly  necessary  to  promote  their 
closure ;  and  I  feel  confident  that"  there  is  nothing  better 
for  immediate  use  than  the  bath  just  recommended.  As 
the  infant,  while  in  this  condition,  may  lose  its  ability  to 
nurse  at  the  breast,  it  should  be  fed  by  a  spoon  with 
warm  maternal  milk.  A  few  drops  of  the  aromatic 
spirit  of  ammonia,  with  sugar,  well  diluted  and  carefully 
administered  may  also  do  good.  As  soon  as  the  child 
is  taken  out  of  the  bath,  the  abdominal  bandage  and 
navel -clothes  should  be  removed,  and  dry  soft  ones  re- 
applied. The  umbilical  surface  should  also  be  anointed 
with  simple  cerate,  to  prevent  ill  effects  from  the  alum 
and  ammonia. 

As  the  crying  of  the  child  is  very  apt  to  disturb  the 
navel,  as  well  as  its  dressings,  great  care  should  be  taken 
during  the  first  eight  or  ten  days  to  prevent  hard  spells 
of  it.  The  abdominal  bandage  should  be  applied  in  anti- 
cipation of  such  paroxysms ;  and  the  dressings  should  be 
examined  daily.  Should  they  become  soiled  with  feces  or 
urine,  they  must  be  removed,  and  clean,  soft  ones  applied. 
All  jolting  or  improper  handling  of  the  infant  should  be 
avoided,  as  much  injury  is  often  done  in  that  way ;  by  it 
the  cord  may  be  ruptured  or  injuriously  stretched. 

The  umbilicus  may  suffer  from  an  improper  mode  of 
dressing :  nurses  have  a  bad  habit  of  clouting  by  pinning 
the  cloth  in  a  bulk  over  the  navel,  which  will  press  directly 
on  it,  whenever  the  child  cries,  strains,  kicks,  or  draws  up 
its  lower  extremities.     This  error  should  be  corrected. 

Spells  of  colic  also  have  a  bad  effect  on  this  part,  and 
afford  an  .additional  consideration  for  giving  as  prompt 


51 

relief  as  passible.     Entire  cleanliness  must  also  be  regarded 
as  one  of  our  prophylactics. 

It  will  sometimes,  though  not  often,  be  necessary  to 
employ  local  medication  of  the  umbilicus  before  the  funis 
is  detached.  Should  the  cord  become  dry  and  hard,  without 
separating  at  the  proper  time,  and  the  surrounding  surface 
irritated  by  it,  it  will  be  necessary  to  raise  the  dressings 
and  apply  a  little  warm  olive  oil ;  or  remove  a  portion  of 
it,  if  it  be  thoroughly  dried,  and  the  parts  well  contracted, 
with  a  sharp  pair  of  scissors.  No  portion  of  the  cord 
should  be  thus  divided,  except  it  be  entirely  dry,  and  its 
vessels  impervious.  Occasionally  it  will  be  necessary 
to  divide  a  small  remaining  thread  of  the  cord,  especially 
if  any  local  applications  are  necessary.  But  even  this 
should  be  done  circumspectly.  On  the  contrary,  should 
healthful  desiccation  not  take  place,  or  only  partially,  and 
the  navel  string  remain  soft  and  large,  attended  with  ul- 
ceration and  suppuration  around  its  base,  the  dressings 
may  be  carefully  removed  and  a  soft  astringent  poultice 
applied,  with  the  double  motive  of  producing  contraction 
of  the  ring  and  allaying  irritation  of  the  inflamed  sur- 
face. A  little  corn  meal  cooked  with  a  decoction  of  oak 
bark,  will  make  the  best  poultice. 

The  funis  occasionally  separates  by  sloughing,  emitting 
a  bad  odor,  and  exhaling  an  irritating  moisture.  In  such 
cases,  the  part  should  be  well  secured  in  a  dry  soft  cloth, 
the  surface  under  it  washed  with  milk  and  water,  and  well 
oiled,  to  protect  it  against  the  irritating  effects  of  tho 
exuding  fluids. 

A  little  fungus  may  spring  up  just  at  the  point  where 


52 

the  cord  separates,  this  should  be  carefully  touched 
with  caustic  a  few  times,  according  to  results. — 
Always  after  the  detachment  of  the  part  the  surface 
around  the  navel  should  be  washed  with  warm  milk  and 
water,  then  well  dried,  and  a  little  simple  cerate  applied 
to  the  surface,  and  a  good  abdominal  bandage  put  around 
as  before ;  the  use  of  which  should  be  continued  for  some 
time;  more  especially  if  there  be  any  tendency  to  a 
pouting  of  the  part. 

Lastly,  after  the  funis  has  separated,  the  umbilicus 
should  be  carefully  washed  with  castile  soapsuds,  and  if 
there  be  the  least  appearance  of  irritation  or  inflamma- 
tion, a  soft  mush  poultice,  twice  the  size  of  a  dollar  and 
about  twice  as  thick,  throughout  its  whole  extent — lest 
the  edges  become  dry — should  be  neatly  spread  on  a  soft 
piece  of  cloth,  then  moistened  on  its  surface  with  a  little 
lead  water  and  olive  oil,  or  prepared  as  before  with  oak 
bark  tea,  and  laid  with  care  immediately  over  the  navel, 
and  should  be  retained  in  its  place  by  a  proper  application 
of  the  bandage.  This  poultice  should  be  removed  in 
six  or  eight  hours  and  another  applied,  and  so  on 
until  all  signs  of  a  morbid  state  of  the  part  entirely 
disappear.  It  will  sometimes  be  necessary  to  continue 
this  course  of  poulticing  for  five  or  six  days,  to  the  entire 
exclusion  of  all  other  topical  applications,  such  as  calomel, 
red  precipitate,  spirits  of  turpentine,  &c,  as  their  prophy- 
lactic powers  are  very  inferior  to  those  of  the  compound 
poultice  just  recommended.  All  predisposing,  accessory  or 
accidental  causes  of  irritation  should  be  guarded  against  with 
great  care;   the  general   health  of  the  child  should  be 


53 

-closely  watched,  and  internal  remedies  employed  if  neces- 
sary. 

Soft,  emollient  poultices,  certainly  afford  even  an  adult, 
suffering  from  a  wound,  greater  protectiou  than  any  other 
means.  Who  «ver  saw  a  patient  attacked  with  traumatic 
tetanus,  who  had  had  all  the  prophylactic  benefits  of  good 
poultices,  a  well  regulated  temperature  of  his  room,  and 
appropriate  internal  remedies?  The  soothing  action  of 
the  poultice  seems  indeed  to  prevent  a  wound  from  passing 
into  that  condition  which  excites  lock-jaw.  The  terminal 
extremities  of  the  wounded  nerves,  or  those  that  have  been 
exposed  by  ulceration,  or  irritated  by  inflammation,  are 
protected  by  a  poultice  against  that  tetano  pathological 
condition  into  which  they  pass  sometimes,  when  not  thus 
guarded,  with  great  facility. 

But  alas!  because  the  inflammation  of  the  navel  is 
trifling,  or  the  ulcer  on  it  small,  the  physician  does  not 
consider  either  worthy  of  his  attention,  when,  really,  the 
the  very  elements  of  death  'are  more  actively  at  work 
than  in  many  cases  which  so  readily  engage  his  closest 
attention  and  greatest  skill.  It  is  probable  that  a  greater 
amount  of  human  life  might  be  saved  by  these  simple 
preventives,  than  most  physicians  or  nurses  are  aware  of; 
and  it  is  always  far  more  difficult  to  procure  the  employ- 
ment of  such  prophylactics,  than  those  uncertain  remedies 
which  are  so  zealously  administered  sometimes  for  the 
relief  of  an  incurable  malady. 

Nurses  should  be  properly  directed  to  employ  these 
means,  especially  among  our  negroes ;  and  every  practi- 
tioner  should    constantly  urge  their  adoption  in    negro 


54 

quarters.  When  these  means  are  faithfully  employed, 
negro  children  escape  tetanus  to  as  great  an  extent 
as  do  white  children.  It  should  be  the  resolve  of 
every  practitioner  never  to  allow  an  infant  to 
be  attacked  with  trismus  that  may  be  delivered  by  him, 
or  placed  under  his  care  at  birth,  since  by  a  patient  and 
careful  employment  of  appropriate  prophylactics  it  may 
be  prevented.  These  means,  simple  and  unpretending  as 
they  are,  require  some  oversight  and  tact  for  their  benefi- 
cial employment :  if  the  poultice  be  not  well  applied,  of 
improper  consistence,  or  become  dry  and  hard,  it  may  do 
more  harm  than  good.  Besides,  if  the  child  be  not  pro- 
tected against  wet  and  soiled  clothing,  bad  air,  variable 
temperature  of  its  room,  a  bad  habit  of  body,  bad  feeding 
and  nursing,  these  predisposing,  accessory  and  accidental 
causes,  may  determine  the  morbid  umbilicus  to  pass  into  a 
traumato-tetanic  condition  in  despite  of  poultices  or  any 
other  topical  applications  whatever ;  so  it  is  highly  neces- 
sary that  all  these  things — little  in  themselves  though 
great  in  their  effects — should  be  scrupulously  regarded 
by  every  practitioner. 

The  writer  of  this  treatise,  while  faithfully  discharging 
his  duty  to  infants  in  the  employment  of  these  prophy- 
lactic measures,  has  often  experienced  the  jeers  and 
taunts  of  nurses  on  such  occasions.  Every  practitioner 
should,  however,  perform  his  duty  to  his  little  patient,  be 
it  white  or  black,  in  protecting  it  against  an  attack  of  a 
disease  which  he  may  prevent  but  cannot  cure,  and  there- 
by impress  nurses,  parents,  and  even  communities  with 
the  great  utility  of  such  a  course.     In  that  way  our  pro- 


55 

phylactics  may  be  raised  above  the  contempt  of  ignorant 
crones  or  those  too  wise  to  learn. 

Admitting,  as  we  are  compelled  to  do,  that  we  can  but 
seldom  treat  this  disease  successfully,  yet  it  will  be  pro- 
per to  give  a  full  detail  of  its  symptoms,  diagnosis/prog- 
nosis, pathology  and  treatment. 

Symptoms. —  These  at  first  are  vevy  obscure,  and  may 
be  overlooked  both  by  the  physician  and  nurse.  It  is 
so  very  common  for  infants  to  cry,  and  thereby  manifest 
only  slight  ailments  that  the  early  symptoms  are  usual- 
ly referred  to  some  ordinary  indisposition  which  does 
not  excite  much  concern. 

During  the  first  week  the  child  has  probably  been  quite 
healthy;  has  nursed  well,  slept  well,  and  has  done  so 
well  in  every  respect,  that  scarcely  any  apprehension  is 
entertained  about  its  safety,  until  on  the  eighth  or  ninth 
day,  when  the  child's  cry  is  modified,  and  evinces  dis- 
tress ;  it  also  whimpers  and  does  not  rest  so  well. 
These  premonitory  symptoms  will  soon  be  followed  by  a 
quickened  pulse,  distress  of  countenance.  These  will 
be  associated  with  other  symptoms  about  this  time,  such 
as  rigidity  of  the  muscles  about  the  neck  and  face,  a 
disinclination  on  the  part  of  the  child  to  nurse,  while 
the  endeavors  of  the  anxious  mother  to  get  it  to  do  so 
may  be  unavailing.  The  child  will  either  push  the  nip- 
ple out  with  its  tongue,  or  in  the  attempt  to  nurse, 
should  it  draw  any  milk  into  its  mouth,  will  strangle 
and  sometimes  very  badly.  The  alarmed  mother  will 
try  again  and  again  to  get  her  child  to  nurse,  supposing 
that  it  has  the  colic,  hives  or  something  of  the  kind.    She 


56 

will  then  probably  try  to  get  her  babe  to  swallow  some 
domestic  remedies,  and  failing  in  that  also,  the  family 
physician  will  be  sent  for;  on  his  arrival  he  will  find  the 
child's  countenance  greatly  changed;  the  skin  on  the 
forefiSd  will  be  wrinkled,  the  eyebrows  knit,  the  skin 
on  the  cheek  drawn  upwards  and  backwards,  also  the 
angles  of  the  mouth,  thereby  thinning  and  compressing 
the  lips  against  the  gums.  The  eyes  will  be  partially 
closed,  and  will  roll  upwards  or  become  fixed  in  their 
sockets.  The  contour  of  the  mouth  will  be  changed, 
sometimes  remaining  slightly  open  in  an  elliptical  form. 
The  under  jaw  is  fixed  and  cannot  be  separated  from 
;he  upper  one,  presenting  now  the  unequivocal  symptom 
)f  Trismus.  The  patho-physiognomy  of  the  disease  is 
now  fully  established.  There  will  now  be  great  rigidity  of 
the  muscles  of  the  neck,  spine,  abdomen  and  extremities. 
The  abdomen  will  feel  hard,  the  extremities  will  be  more 
or  less  stiff,  and  the  back  will  be  curved  either  backwards 
— episthotonos — or  forwards — emprosthotonos — and  in 
some  rare  instances  laterally — pleurosthotonos.  The 
lateral  tetanic  flexure  is  the  most  unusual,  the  procurva- 
tion  the  most  favorable,  and  the  recurvation  the  most 
fatal.  If  the  umbilicus  be  examined  it  will  in  all  pro- 
bability be  found  in  a  pathological  state  of  some  kind, 
most  commonly  inflamed  and  irritable.  As  the  disease 
advances  the  flexure  of  the  spine  backwards — the  most 
common  variety — along  with  the  reversion  of  the  head 
increases.  The  tonic  spasms  become  greater  and  faster; 
they  will  occur  every  twenty,  thirty  or  forty  minutes, 
without  complete  relaxation  of  the  muscles   during  their 


57 

intervals.  All  ability  to  swallow  is  occasionally  lost, 
the  jaws  become  immovably  fixed,  and  in  the  course  of 
twelve,  twenty-four,  or  forty-eight  hours  the  infant  will  be 
destroyed  by  a  hard  spasm  or  die  comatose.  Sometimes, 
however,  infants  live  eight  or  ten  days,  the  disease  then 
becomes  chronic,  and  they  may  recover. 

There  is  seldom  much  or  any  febrile  excitement,  but  on 
the  contrary  often  coldness  of  the  surface  and  extremities. 
The  pulse  is  generally  quickened,  and  the  bowels  torpid. 
The  brain  is  not  much  disturbed  until  towards  the  close  of 
the  malady.  The  symptom  of  Trismus  may  be  com- 
plete, partial  or  not  exist  at  all.  In  the  latter  instance 
the  child  may  continue  to  nurse  and  swallow  through  the 
whole  course  of  the  disease.  The  writer  once  attended 
a  fatal  case  of  this  kind,  which,  a  learned  professor,  who 
incidentally  saw  the  case  while  under  treatment,  attempt- 
ed to  relieve  by  the  use  of  chloroform,  but  failed  most 
signally. 

Hence,  I  infer  that  the  absence  of  trismus,  in  this  dread- 
ful complaint  does  not  lessen  the  danger,  though  the 
disease  presents  a  much  more  favorable  appearance;  for 
when  seen  in  its  trismatic  features,  of  unyielding  spasm 
and  intense  suffering,  the  appearances  are  horribly  dis- 
tressing, and  cannot  be  easily  forgotten. 

I  have  procured  a  very  excellent  likeness  of  this  infan- 
tile patho-physiognomy.  By  the  professional  courtesy  of 
Dr.  Conwell  of  our  city,  I  obfained  leave  of  one  of  his 
families  to  have  a  drawing  taken  of  a  fully  developed 
case,  by  a  very  adroit  lithographist,  Mr.   Wagner.     It 


58 

may  be  seen  and  examined  on  the  annexed  plate.  In 
this  case,  the  umbilicus  was  badly  inflamed,  swollen,  and 
presented  a  very  irritable  appearance.  The  disease  came 
on  about  the  sixth  or  seventh  day.  No  remedies  did  any 
good,  and  the  child  died  in  forty-eight  hours  from  the  attack. 
The  extremities  were  more  affected  than  usual,  and  the 
spine  though  recurvated  considerably,  yet  the  flexure  was 
not  as  great  as  sometimes  occurs,  nor  was  the  head  drawn 
backwards  as  far  as  I  have  seen  it  in  other  cases.  But 
it  was  a  very  plain,  rapid  arid  fatal  case  of  infantile  traumatic 
tetanus.  I  should  further  state  that  in  this  case  the  cord 
sloughed,  which  is  the  worst  manner  in  which  it  can  separate. 
Diagnosis. — This  disease  has  been  confounded  by  most 
writers  with  clonic  spasms  or  convulsions !  Even  Condie, 
a  systematic  writer  on  the  diseases  of  children,  has  done 
so.  If  we  may  judge  from  Jtiis  few  remarks  we  may  infer 
that  he  cared  but  little  about  it.  Other  good  writers  are 
equally  culpable.  Evanson  and  Maunsell  of  Ireland, 
evade  responsibility  about  it  by  stating  that,  "  It  may 
justly  be  considered  as  an  hospital  disease."  Whether  the 
children  of  Ireland  ever  suffer  from  it  out  of  their  hos- 
pitals or  not,  I  am  not  now  prepared  to  answer;  but  I 
know  very  well  that  infants  of  Irish  parents  frequently 
do  in  our  country ;  hence  I  infer  that  it  is  most 
reprehensively  overlooked  among  the  poor  of  that  coun- 
try. Even  the  practical  Dewees  says  he  can  see  nothing 
positively  dangerous  in  a  diseased  navel !  And  West,  a  copi- 
ous writer  on  other  infantile  disorders,  writes  impatiently 
and  confusedly  about  this.  He  even  questions  the  pa- 
thological signs  which  he  has  stated  in  regard  to  it. 


1 


Mr* 


59 

This  much  neglected  pathos  is  by  no  means  without 
its  diagnostic  symptoms ;  signs  by  which  it  may  be  con- 
tradistinguished from  all  other  infantile  convulsions.  These 
are  so  characteristic  of  the  complaint  that  it  is  very 
astonishing  it  should  ever  have  been  confounded  with 
other  nervous  disorders.  They  are  as  plainly  differ- 
ent from  those  attending  such  affections,  as  are  Epileptic 
convulsions  from  tetanic  spasms  in  the  adult.  And  there 
is  no  more  reason  for  confounding  infantile  tetanus 
with  ordinary  clonic  spasms,  than  that  of  adults  with 
epilepsy.  There  is  about  the  same  variety  of  tetanic 
cases  among  the  former  as  is  among  the  latter;  and 
each  variety  is  of  course  attended  with  a  corresponding 
modification  of  symptoms.  These  may  in  both  instan- 
ces be  sometimes  very  mild  and  obscure,  and  in  others 
very  active  and  plain. 

The  symptom  of  Trismus — rarely  ever  absent — aids 
us  more  than  any  other  in  forming  a  correct  diagnosis. 
But  even  in  its  absence  the  rigidity  of  the  muscles  of 
the  neck,  distortion  of  the  spine,  and  the  tonic  unrelenting 
spasm,  would  determine  the  true  nature  of  the  case. 
Besides,  tetanic  spasms  are  unlike  all  other  varieties 
for  they  never  intermit  completely,  but  continue 
in  degree  all  the  while;  nor  do  patients  lose  all  con- 
sciousness during  their  continuance,  as  they  do  generally 
in  convulsions. 

When  all  these  symptoms  are  present,  such  as  trismus, 
reversion  of  the  head,  incurvation  of  the  spine,  tonic 
spasm  of  the  voluntary  muscles,  inability  to  swallow 
without  strangling,  with   an  inflamed  umbilicus,  how,  I 


60 

ask,  could  we  have  a  plainer  case  of  traumatic  tetanus, 
taking  into  consideration  the  fact  that  these  charac- 
teristic symptoms  came  on  about  the  same  time  in  which 
they  would  in  the  person  of  an  adult  after  the  reception 
of  a  wound.  Were  they  to  occur  in  an  adult  case  about 
the  same  time  after  a  wound  the  merest  tyro  in  medicine 
could  hardly  fail  in  diagnosing  the  disease.  Why  then 
should  good  observers  admit  that  the  disease  has  its 
source  in  the  one  case  evidently  in  a  wound,  and  not  in 
the  other? 

On  one  occasion  I  was  requested  to  examine  an  infant 
with  all  the  plain  diagnostic  symptoms  of  traumatic 
tetanus,  by  an  old,  experienced  and  respectable  physician 
who  had  the  case  in  hand,  and  to  my  great  astonishment, 
he  had  entirely  overlooked  the  true  nature  thereof, 
and  but  for  maternal  solicitude  would  have  given  the 
case  but  little  consideration.  He  said  that  I  was  over- 
anxious about  the  child,  that  it  would  be  well  in  a  few  days, 
but  in  this  he  was  mistaken,  for  it  died  in  a  short  time. 
This  infant  had  a  badly  inflamed  navel,  of  which  he  was 
ignorant  until  I  directed  his  attention  to  it.  The  symp- 
toms of  traumatic  tetanus  were  plain,  but  because  they 
occurred  in  an  infant  they  were  disregarded  by  this  prac- 
titioner, and  had  I  not  seen  the  child  the  disease  would 
have  passed  for  something  else.  Thus  we  see  how  this 
fatal  malady  is  doubtless  often  regarded. 

The  observing  physician  who  understands  the  diag- 
nostic signs  of  this  disease,  will  have  but  little  difficulty  in 
making  out  an  acute  case,  but  in  its  chronic  form  there 
may  be  some  difficulty,  especially  if  the  child  be  recov- 


61 

ering  and  the  symptoms  mild.  The  previous  history  of 
the  case  must  be  patiently  enquired  into,  and  the 
symptoms  just  enumerated,  however  mild,  have  diag- 
nostic characteristics.  Most  of  these  signs  are  pathog- 
nomonic, and  generally  there  are  but  few  adjunctive 
ones  to  mislead.  Probably  there  is  no  infantile  dis- 
order more,  clearly  pronounced  by  its  symptoms  than  this 
one,  and  yet  none  has  been  more  overlooked,  mistaken 
and  maltreated! 

Prognosis. — This,  if  our  diagnosis  be  correct,  should  of 
course  be  unfavorable.  A  few  cases  become  chronic  and 
recover,  but  not  a  sufficient  number  to  justify  a  favor- 
able, or  even  an  equivocal  opinion.  An  unfavorable 
prognosis  might,  however,  be  followed  by  the  statement 
that  a  few  recover.  This  will  temper  the  harsh  declar- 
ation a  little;  but  we  should  be  particularly  cautious 
not  to  raise  hopes  which  in  all  probability  may  not  be 
realized.  The  physician's  opinion  should  be  cautiously 
communicated  to  the  mother,  lest  the  shock  of  an  unfa- 
vorable one  injure  her.  Her  puerperal  state  will  re- 
quire this.  It  will  suffice  at  first  to  let  her  know  that 
her  child  is  ill,  and  a  short  time  afterwards  that  it  is 
dangerously  so,  and  at  a  proper  time  that  it  may  die 
very  soon.  A  little  maternal  hope  will  soften  and  qual- 
ify all  these  painful  statements,  and  greatly  lessen  their 
injurious  effects.  Let  her  hope  be  gradually  extin- 
guished, not  too  suddenly,"  for  we  should  not  forget  that 
we  may  be  dealing  with  two  lives !  Besides,  the  physi- 
cian should  be  very  certain  of  the  correctness  of  his 
diagnosis,  before  he  expresses  so  grave  an  opinion.    How 


62 

could  a  mother  excuse   a   mistake  which  might  torture 
her  unnecessarily  for  several  days  and  nights? 

Pathology. — We  know  of  scarcely  any  pathological 
lesions  beyond  the  umbilicus.  Post  mortem  examin- 
ations have  revealed  but  few  if  any.  Although  the 
chief  seat  of  the  disease  be  in  the  spinal  cord  and  spinal 
nerves,  yet  they  do  not  manifest  any  appreciable  patho- 
logical changes  after  death,  significant  thereof,  according 
to  our  most  accurate  observers.  West,  in  his  work  on 
the  diseases  of  children,  states  that  he  found  in  his  ex- 
aminations of  three  cases  after  death,  there  was  an 
effusion  of  blood  in  the  cellular  tissue  surrounding  the 
theca  of  the  cord,  and  a  congested  state  of  the  vessels  of 
the  spinal  arachnoid,  and  sometimes  an  effusion  of  blood  or 
serum  into  its  cavity.  But  in  consequence  of  finding 
similar  appearances  in  the  bodies  of  infants  which  had 
died  of  other  affections,  he  hesitates  to  accept  those  just 
mentioned  as  true  pathological  lesions  of  Trismus  Nas- 
centium.  It  seems  very  reasonable  to  suppose  that  the 
pharanx  and  esophagus,  will  be  found  after  death  con- 
tracted and  inflamed.  Doubtless  in  bad  cases,  the  chief  pa- 
thological signs  after  death,  will  be  found  in  the  spinal  cord,, 
teaching  us  the  importance  of  addressing  active  remedies  du- 
ring life  to  that  part.  As  this  morbus  pervades  the  whole 
spinal  cord,  our  remedies,  for  its  relief,  must  be  prompt, 
active  and  well  directed,  probably  more  so  than  has  gen- 
erally been  done. 

Treatment. — The  management  of  cases  of  this  kind 
would  be  a  better  term  than  the  treatment  of  them  in  a 
medical  sense.     Treatment  will  be  required,  and  we  must 


63 

manage  them  in  the  best  manner.  Although  we  may 
have  lost  confidence  in  all  remedies  in  consequence  of 
their  constant  failures,  yet  we  must  continue  to  employ 
them ;  for  the  particular  case  of  which  we  may  have  the 
management  may  be  an  exceptional  one, "  and  unlike 
others,  may  be  amenable  to  our  remedies. 

Prof.  W.  T.  Briggs,  my  present  co-partner,  has  just  in- 
formed me  that  he  lately  treated  a  well  marked  case  suc- 
cessfully. It  came  on  about  the  usual  time  after  birth, 
and  was  attended  with  a  very  bad  state  of  the  umbilicus. 
The  cord  sloughed  partially  at  first,  and  left  a  portion  in 
a  half  sphacelated  condition,  adhering  to  the  navel,  from 
which  an  irritating  discharge  constantly  exuded,  and 
kept  up  a  great  deal  of  irritation  and  inflammation  of 
the  umbilicus.  But  by  means  of  a  soft  emollient  poul- 
tice to  the  part  and  the  internal  use  of  two  drops  of 
laudanum  every  two  or  three  hours  he  succeeded  in  relieving 
the  little  patient.  The  result  of  this  and  similar  cases 
is  encouraging,  and  teaches  us  that  we  should  always 
try  to  cure  the  disease.  I  will,  therefore,  advise  the 
following  plan  of  treatment : — In  the  first  place  apply  a 
soft  emollient  poultice  to  the  child's  navel,  let  its  condi- 
tion be  as  it  may.  Give  from  one  to  two  drops  of  lauda- 
num every  two  hours,  watching  its  effects :  but  should 
the  child  not  be  able  to  swallow  the  medicine,  employ  it 
as  an  enema  with  a  thin  solution  of  starch — lour  or  five 
drops  repeated  in  that  way  every  three  or  four  hours,  and 
if  this  be  voided  too  early,  clothes  saturated  with  it 
should  be  applied  to  the  epigastrum,  taking  care  that  too 
much  of    the  drug  be   not  absorbed.     If  the  child  be 


64 

plethoric  a  leech  or  two  should  be  applied  to  the  spine, 
and  immediately  afterwards,  its  whole  course  from  the 
occiput  to  the  coccygis  should  be  vesicated,  either  by 
the  vinegar  of  cantharides  or  strong  aqua  ammonia.  It 
is  easy  enough  to  prevail  on  mothers  and  nurses  to  give 
laudanum  and  similar  drugs  in  this  disease,  but  they 
may  object  to  extensive  vesication  of  the  spine;  hence  it 
will  often  be  necessary  to  explain  and  insist  on  this 
particular  remedy. 


EfttUTi..— In  note,  page  45>  for  "  heinorage,'*  read  hemorrhage,    At  page  1^  14th  line,  fef 
"  their, *  read  there. 


I3STDE-X 


Introductory i-xvi 

History 4 

Dr.  Sim's  Theory 5 

Strictures  thereon 6 

Predisposing  Causes 11 

The  Exciting  Cause 14 

Separation  of  the  Umbilical  Cord 15 

Remarks  on  Dr.  Joseph  Clark's  views 17 

Condition  of  Infant  at  Birth 18 

Negro  Children 20 

Prevalence  of  the  Disease  at  Particular  places 22 

Contribution  from  Dr.  McCulloch 24 

"         "         "      Dr.  Ransom 26 

"     .    "         "      Dr.  Black 28 

"         "         "      Dr.  Morton 29 

Inflammation  of  the  Umbilicus 36 

Trismus  Nascentium.  essentially  the  same  as  traumatic  tetanus  in  the  adult.  37 

Prophylaxis 30 

Division  of  the  Umbilical  chord 41 

Mode  of  dressing  the  Umbilicus 41 

The  fetal  parts  which  contract  at  birth 43 

The  Anatomy  of  the  Umbilicus 44 

Plate,  with  references 46 

Physiological  Lesions 45 

Management  of  the  Umbilicus 1 50 

Poultices 52 

Symptoms  of  the  Disease 55 

Diagnosis 58 

Plate  2 58 

Prognosis 61 

Pathology 62 

Treatment 62 


*D058805 


